Chapter 4 Marine accident and serious incident investigations

Chapter 4 Marine accident and incident investigations

1. Marine accidents and incidents to be investigated

<Marine accidents to be investigated>
◎Paragraph 5, Article 2 of the Act for Establishment of the Japan Transport Safety
Board (Definition of marine accident)
The term "Marine Accident" as used in this Act shall mean as follows:
1. Damage to a ship or facilities other than a ship related to the operations of a ship.
2. Death or injury of the people concerned with the construction, equipment or
operation of a ship.

<Marine incidents to be investigated>

◎Item 2, paragraph 6, Article 2 of the Act for Establishment of the Japan Transport
Safety Board (Definition of marine incident)
A situation, prescribed by Ordinance of Ministry of Land, Infrastructure, Transport
and Tourism, where deemed to bear a risk of Marine Accident occurring.

◎Article 3 of Ordinance for Enforcement of the Act for Establishment of the Japan
Transport Safety Board
(A situation, prescribed by Ordinance of the Ministry of Land, Infrastructure,
Transport and Tourism, stipulated in item 2, paragraph 6, Article 2 of the Act for
Establishment of the Japan Transport Safety Board)
1. The situation wherein a ship became a loss of control due to any of the following
reasons:
(a) navigational equipment failure;
(b) listing of a ship; or
(c) short of fuel or fresh water required for engine operation.
2. The situation where a ship grounded without any damage to the hull; and
3. In addition to what is provided for in the preceding two items, the situation where
safety or navigation of a ship was obstructed.

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 Chapter 4 Marine accident and serious incident investigations

<Category of marine accident and incident>

Marine accident and incident to be

Type of marine accident and incident
investigated

Collision, Grounding, Sinking, Flooding,

Damage to ships or other facilities
Marine accident

Capsizing, Fire, Explosion, Missing,

involved in ship operation
Damage to facilities

Casualty related to ship structures, Death, Death and injury, Missing person,
equipment or operations Injury

Loss of control (engine failure, propeller

Navigational equipment failure
failure, rudder failure)

Listing of ship Loss of control (extraordinary listing)

Marine incident

Short of fuel or fresh water Loss of control (fuel shortage, fresh water
required for engine operation shortage)

Grounding without hull damage Stranded

Obstruction of ship safety or Safety obstruction, Navigation

navigation obstruction

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Chapter 4 Marine accident and serious incident investigations

2. Procedure of marine accident/incident investigation

Occurrence of marine
accident or incident District Transport Bureau
(Maritime Safety and
Report Ship master,
Environment Department,
Ship owner, etc.
Notice etc)
Notification of marine
accident or incident Coast Guard Officer, Police
Officer, Mayor of Municipality

Initiation of investigation ・Appointment of investigator-in-charge and other investigators

・Coordination with relevant authorities, etc.
・Notification to interested states

Fact finding investigation ・Interview with crew members, passengers, witnesses, etc.
・Collection of relevant information such as weather or sea conditions
・ Collection of evidence relevant to the accident, such as VDR
records, AIS records, and examination of ship damage
Initial report to the Board

Examination, test and analysis

・Marine Committee (for serious cases) or Marine Special Committee

(for non-serious cases)
Deliberation by the Board ・General Committee or the Board for very serious cases in terms of
(Committee) damage or social impact

【Hearings, if necessary】

Comments from parties ・Parties relevant to causes, upon their request, are permitted to
concerned make comments accompanied by assistants, or at an open meeting.

・Invite comments from substantially interested states and parties

concerned (sending a draft investigation report)
Deliberation and adoption by
the Board (Committee)

Submission of investigation
・Submission of report to the IMO and interested states
report to the Minister of Land,
Infrastructure, Transport and
Tourism

【Recommendations or expression of opinions, if necessary】

Follow-up on The Minister of Land, Infrastructure, Transport

Publication recommendations, and Tourism and parties relevant to the causes
opinions, etc. of the accident or serious incident involved
implement measures for improvement and
notify or report these to the JTSB.

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 Chapter 4 Marine accident and serious incident investigations

3. Jurisdiction of the Offices over marine accidents and incidents

For the investigation of marine accidents and incidents regional investigators are
stationed in the regional offices (eight offices). Our jurisdiction covers marine accidents and
incidents in the waters around the world, including rivers and lakes in Japan. The regional
offices are in charge of investigations in the respective areas shown in the following map.
Marine accident investigators in the Tokyo Office (Headquarters) are in charge of serious
marine accidents and incidents.

Hakodate

Sendai

Sendai
Moji
Hiro Kobe
shima
Yokohama

Nagasaki
Kobe
Moji
Moji Hiroshima

Kobe
Naha

Hakodate

Kobe

Yokohama

Kobe

Jurisdiction map

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Chapter 4 Marine accident and serious incident investigations

4. Role of the Offices and Committees according to category of accident and

incident
Serious marine accidents and incidents are investigated by the marine accident
investigators in the Headquarters, and are deliberated in the Marine Committee.
Non-serious marine accidents and incidents are investigated by regional investigators
stationed in the eight regional offices, and deliberated in the Marine Special Committee.

Office in charge of investigation: Marine accident

Serious marine investigators in the Headquarters
accidents and incidents Committee in charge of deliberation and adoption:
Marine Committee

Definition of “serious marine accidents and incidents”

•Cases where a passenger died or went missing, or two or more passengers were
severely injured.
•Cases where five or more persons died or went missing.
•Cases involved a vessel engaged on international voyages where the vessel was
a total loss, or a person on the vessel died or went missing.
•Cases of spills of oil or other substances where the environment was severely
damaged.
•Cases where unprecedented damage occurred following a marine accident or
incident.
•Cases which made a significant social impact.
•Cases where identification of the causes is expected to be significantly difficult.
•Cases where essential lessons for the mitigation of damage are expected to be
learned.

Office in charge of investigation: Regional

Non-serious marine investigators in the regional offices
accidents and incidents Committee in charge of deliberation and adoption:
Marine Special Committee

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5. Statistics of investigations of marine accidents and incidents

The JTSB carried out investigations of marine accidents and incidents in 2012 as follows:
Investigations into 790 accidents had been carried over from 2011, and 981 accident
investigations newly launched in 2012. Investigation reports on 978 accidents and four interim
reports were published in 2012, and thereby 789 accident investigations were carried over to
2013.
Investigations into 103 incidents had been carried over from 2011, and 165 incident
investigations newly launched in 2012. Investigation reports on 158 incidents were published,
and thereby 109 incident investigations were carried over to 2013.
Among the 1,136 reports published in 2012, six were issued with recommendations, two
with safety recommendations, four with opinions, and 33 with remarks.

Investigations of marine accidents and incidents in 2012

(cases)
Transferred to Tokyo Office
Carried over from 2011

Carried over to 2013

investigation report

Recommendations
Launched in 2012

recommendations
Category
Not applicable

Publication of

Interim report
Remarks
Opinions
Safety
Total

Marine accident 790 981 -4 0 1767 978 6 2 4 33 789 4

Tokyo Office
(Serious cases)
24 22 28 74 42 6 2 4 32 32 4

Regional Offices
(Non-serious 766 959 -4 -28 1693 936 1 757
cases)

Marine incident 103 165 -1 0 267 158 0 0 0 0 109 0

Tokyo Office
(Serious cases)
0 0 0 0 0

Regional Offices
(Non-serious 103 165 -1 267 158 109
cases)

Total 893 1146 -5 0 2034 1136 6 2 4 33 898 4

Note 1: The column “Not applicable” shows the number of cases which did not come under the category of
accident or incident as defined in Article 2 of the Act for Establishment of the Japan Transport Safety Board.
Note 2: The column “Transferred to Tokyo Office” shows the number of cases where the investigation found out
that it was serious and the jurisdiction was transferred from the regional office to the Tokyo Office.

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Chapter 4 Marine accident and serious incident investigations

6. Statistics of investigations launched in 2012

(As of the end of April, 2013)

(1) Types of accidents and incidents

The 1,146 investigations launched in 2012 are classified by types as follows: With
regard to marine accidents, there were 266 cases of grounding, 256 cases of collision, 154
cases of casualty, and 133 cases of contact. With regard to marine incidents, there were 118
cases of loss of control (including 76 cases of machinery failure, 10 cases of rope entangling,
etc.), 37 cases of navigation obstruction, and 6 cases of stranded. The objects of contact were
quays in 44 cases, breakwaters and breakwater blocks in 15 cases.
Number of marine accidents and incidents by type
Sinking, 5 Vessel missing, 1

Marine
58
accident 256 133 266 35 154
(981 cases) 25 46

Explosion, 2
Stranded, 6

Marine
incident 118 37
(165 cases)
Safety obstruction, 4
0 500 1000
Collision Contact Grounding (Cases)
Sinking Flooding Capsizing
Fire Explosion Vessel missing
Facility Damage Casualty Loss of control
Stranded Safety obstruction Navigation obstruction

(2) Types of vessels

The number of vessels involved in marine accidents and incidents is 1,509. Those
vessels are classified by type as follows: 494 fishing vessels, 304 cargo ships, 249 pleasure
boats, 95 tug boats, push boats, 75 tankers, and 73 passenger ships. The total of the three
categories of fishing vessels, cargo ships, and pleasure boats is 1,047, accounting for nearly
70 % of all the accidents and incidents.

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(Vessels) Number of vessels involved in marine accidents and incidents by type

600
500 494

400
304
300 249
200
75 95
100 73 35 36 60 61
7 13 7
0

The number of foreign-registered vessels involved in marine accidents and incidents

was 121, and they were classified by accident type as follows: 64 vessels in collision, 19
vessels in grounding, and 10 vessels in contact. As for the nationality of vessels, 30 vessels
were registered in Panama, 19 vessels in Cambodia, 18 vessels in South Korea. The number
of vessels registered in Asian countries or regions was accounting for about 50% of the
accidents and incidents.

Number of foreign-registered vessels by nationality

(Vessels)
Panama 30 Singapore 6 Cyprus 3 Kiribati 2
Cambodia 19 Russia 4 Philippines 3 Mongolia 2
South Korea 18 Liberia 4 China 3 Bahamas 2
Marshall United States of 3 Others 13
Belize 6 3
Islands America

(3) Number of casualties

The number of casualties was 429, consisting of 112 deaths, 29 missing persons, and
288 injured persons. By type of vessel, 173 persons in fishing vessels and 101 persons in
pleasure boats. By type of accident, 175 persons in casualties (not involved in other types of
accidents), 112 persons in collision, 65 persons in contact, and 34 persons in sinking or
capsizing.
With regard to persons dead or missing, 88 persons were involved in fishing vessel
accidents, 30 persons in pleasure-boat accidents, indicating dead or missing cases occurred
frequently in fishing vessels.
In September 2012, a foreign-registered cargo ship collided with a bonito pole-and-line
fishing boat on the high seas at the east offshore of Kinkazan, Miyagi Prefecture, causing 13
fishing boat crew members to go missing.

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Chapter 4 Marine accident and serious incident investigations

Number of casualties (marine accident)

(Persons)
2012
Dead Missing Injured
Vessel Type Total
Crew Passenger Others Crew Passenger Others Crew Passenger Others
Passenger
ship 2 1 1 0 0 0 6 16 1 27
Cargo ship 6 0 1 0 0 0 7 0 1 15
Tanker 3 0 0 0 0 0 6 0 0 9
Fishing vessel 58 0 2 27 0 1 79 0 6 173
Tug boat,
push boat 2 0 0 0 0 0 7 0 0 9
Recreational
fishing vessel 1 0 0 0 0 0 1 17 0 19
Angler tender
boat 0 1 0 0 0 0 2 10 0 13
Work vessel 1 0 0 0 0 0 1 0 1 3
Barge, Lighter 0 0 1 0 0 0 0 0 0 1
Public-service
ship 1 0 0 0 0 0 0 0 0 1
Pleasure boat 20 0 9 0 0 1 29 0 42 101
Personal
water craft 1 0 1 0 0 0 11 0 40 53
Others 0 0 0 0 0 0 1 0 4 5

95 2 15 27 0 2 150 43 95
Total 429
112 29 288

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7. Summaries of serious marine accidents and incidents which occurred in 2012

The serious marine accidents which occurred in 2012 are summarized as follows: The
summaries are based on information available at the start of the investigations and therefore,
may change depending on the course of investigations and deliberations.

(Marine accident)
Vessel type and name
No. Date and Location Summary
Accident type
1 Jan. 11, 2012 Cargo ship GUANG DA While mooring the ship at the berth
Keiyo Foods Complex South (Panama) referenced in the left column, a stand
Berth, Funabashi City, Chiba Fatality to a crew roller to secure a mooring line on the bow
Prefecture member deck was broken and blown. One Chinese
crew member working in the vicinity of the
stand roller was found unconscious and
confirmed dead later on.

2 Jan. 24, 2012 Cargo ship RYUEI The starboard anchor of the ship leaving
Around 229.4° true, 3.73 Facility damage Tomakomai Port for Hakodate Port was
nautical miles from the dropped while underway, damaging the
lighthouse on Zenigame submarine cable.
South Breakwater in Shinori
Port, Hakodate City,
Hokkaido Prefecture

3 Feb. 7, 2012 Container ship KOTA In East Section of Niigata Port, the
East Section of Niigata Port, DUTA (Singapore) container ship, KOTA DUTA collided with
Niigata City, Niigata Cargo ship TANYA the cargo ship, TANYA KARPINSKAYA
Prefecture KARPINSKAYA causing the TANYA KARPINSKAYA
(Vladivostok) sunken.
Collision

4 Feb. 7, 2012 Chemical tanker While the tanker having the master,
Sakai Semboku Section 7 of KYOKUHO MARU No. 2 second officer, and other 3 members
Hanshin Port Fatality to a crew onboard was navigating northward for
member Umemachi Terminal in Osaka Section 1 of
Hanshin Port after she departed from
Komatsu Wharf of Izumiotsu Port,
Izumiotsu City, Osaka Prefecture, the
chief engineer found the second officer
fallen in the port side No. 1 cargo tank.
The second officer was rescued. Being
unable to breathe air due to inhaling of
chloroform gas, the officer was confirmed
dead due to lack of oxygen.

5 Mar. 4, 2012 Fishing vessel OURA The fishing vessel, OURA MARU, while
Around 4 km northwest of MARU underway, collided with the recreational
Sunosaki, Tateyama City, Recreational fishing fishing vessel, IKU MARU No. 5 having 6
Chiba Prefecture vessel IKU MARU No. 5 passengers onboard and anchoring. One of
Collision the passengers onboard the IKU MARU
No. 5 was killed and the skipper got
injured. The structure of the IKU MARU
No. 5 from its bow to stern was severely
damaged.

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Chapter 4 Marine accident and serious incident investigations

Vessel type and name

No. Date and Location Summary
Accident type
6 Mar. 8, 2012 Cargo ship JNS-2 (South The fishing vessel CHOHO MARU while in
In the vicinity of the No. 1 Korea) operation collided with the cargo ship
light beacon in Iyonada Traffic Fishing vessel CHOHO JNS-2 navigating from Fukuyama to
Route offshore of Iwaishima MARU South Korea and the fishing vessel was
Island, Kaminoseki Town, Collision (with fishing capsized. The skipper of the fishing vessel
Yamaguchi Prefecture gear) fell into the sea. He was lifted and
recovered but died.
7 Mar. 23, 2012 Fishing vessel KASUGA The vessel navigating from Ibusuki Port to
On East China Sea at about MARU the fishing ground in Okinawa Prefecture
120 km west-northwest of Capsizing was found capsized. 4 fishermen were
Naze Port, Naze City, rescued and 2 fishermen went missing.
Kagoshima Prefecture (Found
at this location)
8 Mar. 25, 2012 Pleasure boat MIHO VII The boat having the skipper and 4 persons
About 10 km southeast of Capsizing onboard was capsized while she was
Shiraoi Port, Shiraoi Town, returning to port after fishing.
Hokkaido Prefecture Two persons were dead and one went
missing.
9 Mar. 27, 2012 Container ship ANNA In running the periodical inspection of
Rokko Island RC-5 Wharf, MAERSK such riggings as life boats of the container
Kobe Section of Hanshin Port (Denmark) ship while she was mooring and loading at
Fatality and injury to the Rokko Island, Kobe Section of Hanshin
crew members Port, a life boat overhung outboard fell,
causing one able seaman and the chief
officer, both on the life boat, fatally and
seriously injured, respectively.
10 Apr. 15, 2012 Container ship YONG The container ship YONG CAI navigating
Around 031.5° true, 3.5 nm CAI west-northwestward off the north of Noto
from Rokkosaki Lighthouse (Saint Vincent and Peninsula, Ishikawa Prefecture collided
located in Suzu City, Ishikawa Grenadines) with the fishing vessel SHINYO MARU
Prefecture Fishing vessel SHINYO No. 2 navigating southwestward. The
MARU No. 2 skipper of the vessel died and a crew
Collision member went missing. The YONG CAI
sustained scratches on her starboard, and
the bow section of SHINYO MARU No. 2
was crushed by pressure.
11 Apr. 20, 2012 Container ship EVER The container ship, while her mooring
Around 038° true, 1,360m UNISON operation, contacted with the berth, which
from the lighthouse on the (Singapore) resulted in a dent on her hull and damage
south breakwater of Osaka Contact (with berth) to parking stoppers on the berth.
North Port located Osaka City,
Osaka Prefecture
12 May 15, 2012 Passenger ferry OSADO On the ferry mooring at the wharf
Bandai Jima Wharf of MARU referenced in the left column, one
Niigata West Port, Niigata Fatality to a passenger passenger was found wounded on the head
City, Niigata Prefecture and dead on the car deck.
13 May 23, 2012 Angler tender boat The boat having three anglers onboard
In the vicinity of the north end ARAKAZE contacted with the vicinity of the tip of
of West Breakwater, Section 4 Contact (with West Breakwater of Rumoi Port while she
of Rumoi Port, Rumoi City, breakwater) was taking them from Rumoi Port to the
Hokkaido Prefecture West Breakwater. The skipper and one of
the anglers were injured and the bow
section of the boat was damaged.

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Vessel type and name

No. Date and Location Summary
Accident type
14 June 7, 2012 Cargo ship JUNIPER While the ship navigating from Incheon
In the ship navigating in the PIA (South Korea) Port, South Korea to JFE Steel No. 2
vicinity of No.7 light beacon at Fatality to a crew Export Berth in JFE Steel West Japan
JFE Steel Fukuyama Port, member Works, one of crew members fell into a
Fukuyama City, Hiroshima cargo hold and was confirmed dead.
Prefecture

15 June 24, 2012 Passenger ship ANEI GO The ship, navigating from Nakama Port of
Off the south of Nakama Port, No. 3 Iriomote Island, Taketomi Town to
Taketomi Island, Okinawa Injury to a passenger Hateruma Fishery Harbor of Taketomi
Prefecture Town, was shaken up and down at the area
referenced in the left column and one
passenger was injured.

16 June 26, 2012 Passenger ship ANEI GO The ship navigating from Ishigaki Port of
Off the south-southwest of No. 38 Ishigaki City to Hateruma Fishery Harbor
Nakama Port, Taketomi Injury to a passenger of Taketomi Town was shaken up and
Island, Okinawa Prefecture down at the area referenced in the left
column and one passenger was injured.

17 July 3. 2012 Container ship TIAN FU The container ship TIAN FU navigating
In Mizushima Port, Kurashiki (China) from Komatsu Jima Port in Tokushima
City, Okayama Prefecture Chemical tanker Prefecture to Mizushima Port collided
SENTAI MARU with the chemical tanker SENTAI MARU
Collision navigating from Sodegaura Port in Chiba
Prefecture to Mizushima Port. The port
side of TIAN FU collided with the bow
section of SENTAI MARU.

18 July 3. 2012 Chemical tanker CHEM Two crew members of the tanker
Off the north of Heigun Island, HANA (South Korea) navigating the area referenced in the left
Yanai City, Yamaguchi Fatality to crew column inhaled gas and were in the
Prefecture members critical condition. These members were
transported to the hospital by the patrol
craft of the Japan Coast Guard and
ambulance dispatched in response to the
emergency call but they were confirmed
dead.

19 Sep. 24, 2012 Cargo ship NIKKEI In the area referenced in the left column,
About 900 km east of TIGER the cargo ship NIKKEI TIGER navigating
Kinkasan Island, Miyagi (Panama) from Shibushi Bay of Kagoshima
Prefecture Fishing vessel HORIEI Prefecture to Vancouver (Canada) collided
MARU with the fishing vessel HORIEI MARU
Collision navigating south to evade from the low
pressure and 13 crew members of the
vessel went missing.

20 Oct. 6, 2012 Cargo ship SAGE While unloading the cargo on the ship
Tokuyama-Kudamatsu Port, SAGITTARIUS moored at Kudamatsu Coal Relay Station
Yamaguchi Prefecture (Panama) of Tokuyama-Kudamatsu Port, a
Fatality to a superintendent was found caught in the
superintendent loading/unloading belt conveyor and
confirmed dead by the rescue team.

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Chapter 4 Marine accident and serious incident investigations

Vessel type and name

No. Date and Location Summary
Accident type
21 Oct. 10, 2012 Passenger ship PHENIX The ship leaving Tsu and navigating to the
Around 2.5 nm east of Fire Central Japan International Airport
Kawage, Tsu City, Mie Station was on fire from her port engine
Prefecture when the said engine stopped running due
to its failure. The fire was extinguished by
the crew and 18 passengers changed to
another ship operated by the Tsu Airport
Line, and the ship entered in the Tsu
Airport Line Terminal.

22 Oct. 12, 2012 Angler tender boat The boat drifted due to her engine failure
Shore west of Hirose, Hirado SHOEI MARU No. 18 and grounded on the shore. One of
Seto, Nagasaki Prefecture Grounding passengers fell in the sea and was drowned
when the passenger was transferring to
land.

23 Nov. 14, 2012 Passenger ship GINGA The ship having passengers onboard
Shallowly submerged reef off Grounding including high school students on their
the southeast of school trip and navigating from
Suo-oshimacho Islands, Matsuyama Port of Ehime Prefecture to
Yamaguchi Prefecture Ihota Port of Suo-oshimacho, Yamaguchi
Prefecture, grounded on the hidden reef
referenced in the left column.

24 Dec. 3, 2012 LNG tanker LNG ARIES The electric power in the tanker having
Off the southeast of Toden (Marshall Islands) the master, chief engineer and other 32
Ogishima LNG Berth, Loss of control crew members onboard was lost when she
Kawasaki Section 2 of Keihin (Machinery failure) was approaching the location referenced in
Port the left column to unload her cargo after
loading the LNG at the State of Qatar.

25 Dec. 11, 2012 Gravel carrier SEIWA An explosion occurred within the
In the carrier mooring at the MARU boatswain's store while the carrier was
ship mooring facilities on the Explosion mooring at the facilities referenced in the
right bank of Okawa River at left column. One of the crew members
3-2, Nagara-higashi, Kita died, another one in the boatswain's store
Ward, Osaka City was seriously injured and the master and
one crew member of other ship who were in
the facilities were slightly injured. The
explosion damaged the bow deck seriously,
scattered the shipping goods and part of
hull, and damaged the ships mooring in
the vicinity, buildings and cars in the
neighborhood.

26 Dec. 26, 2012 Racing boat (unnamed) While training for the time trial race of the
Kurobe River, Tohnosho Town, Capsizing single scull (i.e., a rowing boat rowed by
Chiba Prefecture single person), 18 of 34 boats capsized
making the rowers (high school students)
fallen in the water. All of them were
rescued but 6 of them were taken to the
hospital due to their symptom of
hypothermia.

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Column Voice Analysis of VDR Data (Encounter with Tagalog)

The Voyage Data Recorder (VDR), the installation of which has been enforced since July
2002 in pursuant with the International Convention for Safety of Life at Sea (SOLAS), is
equipment similar to the cockpit voice recorder on the aircraft. It records such voice data as
communications among the crew members in the bridge and is now the major tool to help clearing
up the causes of the marine accidents.

Today, it is alleged that one or more of five crew members onboard the merchant vessels
worldwide are the Pilipino (300 thousands or more). Speaking of the Pilipino crew members on
Japanese ocean-going merchant fleet, it is accounting for 70% of the entire crew members, and it
is not unusual that all the members on the bridge are Pilipino. In some occasions the voices
(communications in the bridge) recorded in the VDR before and after an accident are almost all in
Tagalog.

An investigation of an accident turns out to be a painstaking job if we have to understand

the communications carried out with unfamiliar, rare-to-hear language. In the first and urgent
task of an investigator in charge of the accident is to find an interpreter. As can be understood
easily, the language is more rarely spoken the interpreter of that language is harder to find. On
the top of this, there are a lot of other languages spoken in Philippine than its official language
(Tagalog), and crew members may sometimes speak their own individual dialect, which make us
to find an interpreter widely acknowledgeable to languages spoken in Philippine as well as
Tagalog.

The voice data can be analyzed only after the reliable interpreter becomes available, and in
most of the cases the investigator together with the interpreter keep investigating the accident by
carefully listening to the voice communications and by trying to catch the real meanings conveyed
with the communications, because communications among the bridge team members can be heard
intermittently more often (in spite of the noise elimination to the maximum level of efforts). This
difficulty of comprehending the communications is because that the microphone mounted on the
ceiling of the bridge will pick up such noises as winds and rains outside in the case of the bad
weather conditions (under which the marine accidents are susceptible to happen) in addition to a
variety of voices and noises inside of the bridge, and because that there will be a lot of terms and
wordings inherent to marine and shipping industries, to which the interpreter will be unfamiliar.

English will remain as the lingua franca of the sea in the world. On the other hand, the
advent of the VDR in the investigation of causes of the marine accidents revealed the importance
of understanding the mother tongue of individual crew member. We are going to encounter, in the
course of our carrier of the marine accident investigations, a variety of languages worldwide since
the crew on the vessels, coming from worldwide and navigating around Japan, have such
nationalities as Turkey, Russia, and countries in the Eastern European needless to address such
Asian countries as Philippine, China, South Korea, and Myanmar.

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8. Publication of investigation reports

The number of investigation reports of marine accidents and incidents published in 2012
was 1,136 composed of 978 marine accidents (among them, 42 were serious) and 158 marine
incidents.
Looking those accidents and incidents by type, there were 280 cases of collision, 250 cases
of grounding, 159 cases of casualty, and 140 cases of contact in marine accidents. Whereas in
marine incidents, there were 114 cases of losses of control, (including 59 cases of machinery
failure, seven cases of propeller failure, and six cases of out-of-fuel), 28 cases of navigation
obstruction, and 12 cases of stranded.
As for the objects of contact, 40 were quays, 22 were breakwaters, nine were light beacons,
and so forth.

Marine accidents (978 cases):

平成24年に調査報告書を公表した Marine incidents (158 cases):
平成24年に調査報告書を公表した
reports publicized in 2012 reports publicized in 2012
(Cases) 船舶事故（978件） (Cases) 船舶インシデント（158件）
500
500 150
150

114
114
400
400

280
280 100
100
300
300 250

200
200 159
159
140 5050
58 2828
100
100
30 25 36
36 1212
44
00 00
運航不能
Loss of 運航阻害 Stranded
Navigation 座洲 安全阻害
Safety
control obstruction obstruction

The number of vessels involved in marine accidents and incidents was 1,509. Looking
those vessels by type, the vessels involved in marine accidents were 446 fishing vessels, 261
cargo ships, 231 pleasure boats, 84 tankers, and 77 tug boats, push boats. The vessels involved
in marine incidents were 57 fishing vessels, 28 pleasure boats, 20 cargo ships, and 19 passenger
ships. The sum of the number of fishing vessels, cargo ships, and pleasure boats involved in
accidents or incidents is 1,043, accounting for about 70 % of all the vessels involved in accidents
or incidents.

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 Chapter 4 Marine accident and serious incident investigations

Number of vessels involved in marine accidents and incidents by type

(Vessels)

Personal water craft

Tug boat, push boat

Recreational fishing

Public-service ship
Angler tender boat
Passenger ship

Fishing vessel

Barge, Lighter

Pleasure boat
Work vessel
Cargo ship

Tanker

Others
vessel

Total
Type

Marine
accident 47 261 84 446 77 35 6 32 47 16 231 49 16 1,347

Marine
incident 19 20 17 57 7 4 0 2 3 0 28 4 1 162

Total 66 281 101 503 84 39 6 34 50 16 259 53 17 1,509

4.4 18.6 6.7 33.3 5.6 2.6 0.4 2.3 3.3 1.0 17.2 3.5 1.1 100.0
%
% % % % % % % % % % % % % %

List of published investigation reports on serious marine accidents (2012)

Date of
No. Date and Location Name of Accident Summary
publication
1 Jan. 27, Dec. 31, 2009 1st accident: 1st accident
2012 Off the Chemical tanker The chemical tanker SAMHO HERON was
southwest of SAMHO HERON navigating northeastward off the southwest
Kajitori-no-Hana (Malta) of Kajitori-no-Hana and the cargo ship
, Imabari City, Cargo ship GOLDEN GOLDEN WING was navigating
Ehime WING southeastward in the same area. Two
Prefecture (South Korea) vessels collided with each other. The port
Collision bow of the SAMHO HERON was breached
and port stern was dented. The bow of the
2nd accident: GOLDEN WING was cracked and dented
Chemical tanker and the starboard stern was dented. But no
SAMHO HERON fatality or injury was caused on both
(Malta) vessels.
Cargo ship CHIZURU
MARU * The report included Remarks
Collision
2nd accident
The SAMHO HERON was navigating
southeastward after colliding with the
GOLDEN WING around the location of the
1st accident and the cargo ship CHIZURU
MARU was navigating southwestward
behind the port side of the GOLDEN WING.
Two vessels collided with each other. The
SAMHO HERON sustained damage in the
bow, and the CHIZURU MARU sustained
the dent damage in her starboard
mid-section. But no fatality or injury was
caused on both vessels.

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Date of
No. Date and Location Name of Accident Summary
publication
2 Jan. 27, Feb. 13, 2010 Cargo ship TY EVER The cargo ship TY EVER was navigating
2012 Kanmon Passage (South Korea) eastward in the Kanmon Passage of
of Kanmon Port, Cargo ship LOFTY Kanmon Port and the cargo ship LOFTY
off west of HOPE HOPE was navigating westward in the same
Mojisaki, Moji (Cambodia) Passage. Two ships collided with each other.
Ward, Collision The bow of the TY EVER was breached, and
Kitakyushu the port stern of the hull of the LOFTY
City, Fukuoka HOPE was breached. But no fatality or
Prefecture injury was caused on both ships.

* The report included Remarks

3 Jan. 27, Mar. 23, 2010 Cargo ship WIEBKE The cargo ship WIEBKE leaving Masan Port
2012 Kanmon Passage (Antigua and of South Korea for Kobe Section of Hanshin
of Kanmon Port, Barbuda) Port was navigating eastward in the
off Mojisaki, Cargo ship MARINE Kanmon Passage of Kanmon Port, and the
Kitakyushu PEACE cargo ship MARINE PEACE leaving Pohang
City, Fukuoka (Belize) Port of South Korea for Imabari Port,
Prefecture Collision Imabari City, Ehime Prefecture was
navigating eastward in the Kanmon
Passage. The starboard mid-section of the
WIEBKE collided with the port bow of the
MARINE PEACE off the Mojisaki, Kanmon
Passage. The WIEBKE sustained scratches
on her starboard side mid-section and stern,
and the MARINE PEACE sustained
scratches on her port bow and stern. But no
fatality or injury was caused on both ships.

* The report included Remarks

4 Jan. 27, May 17, 2010 Cargo ship MIHARU The ship navigating eastward off the
2012 Off the MARU northwest of Otate Island grounded on the
northwest of Grounding Irose Reef located off the northwest of the
Otate Island, Island. The chief engineer sustained minor
Saikai City, injury on his fingers on the right hand and
Nagasaki the hull of the ship's bottom sustained
Prefecture scratches and dent damage.

* The report included Remarks

5 Jan. 27, June 2, 2010 Motor boat QUEEN The boat contacted with the revetment of
2012 Kawasaki III the construction area in the Kawasaki
Section 1 of Contact (with Section 1 when she was turning to starboard
Keihin Port revetment) to enter the Kawasaki Passage in the
Kawasaki Section 1 of Keihin Port after
navigating southwestward off the southeast
of the Tokyo International Airport. All of
four passengers onboard the boat sustained
injuries and the boat sustained breaches on
her bow and the hull of starboard bow.

* The report included Remarks

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Date of
No. Date and Location Name of Accident Summary
publication
6 Jan. 27, June 18, 2010 Cutter (unnamed) During the rowing training of the cutter
2012 Northern part of Capsizing carried out as the outdoor activity of the
Lake Hamana, junior high school students at Mikkabi
Hamamatsu Youth Center in Shizuoka Prefecture, the
City, Shizuoka winds and waves became too rough to keep
Prefecture training and the cutter was towed by the
motor boat of the Mikkabi Youth Center.
The cutter being towed southwestward off
the south of Sakume of Lake Hamana
capsized portside. One of students confined
within the capsized cutter was killed. One of
oars was broken but the hull sustained no
damage.

* The report included Recommendations and

Remarks

7 Jan. 27, Sept. 19, 2010 Passenger ship The flooding in the engine room was found
2012 Around the pier KASHIMA while the ship was moored to the floating
of the inner Flooding pier in the Hojo Port. In addition to the bilge
harbor inside of water within the reverse and reduction gear
Hojo Port, box attached to the main engine of the ship,
Matsuyama the generator, cell motor for the main
City, Ehime engine, bilge pump, etc. were gotten wet and
Prefecture damaged.

* The report included Remarks

8 Jan. 27, Nov. 17, 2010 Cargo ferry The ferry navigating southward in the Naze
2012 Breakwater off NANKAI MARU No. Port contacted with the breakwater
the Naze Port, 3 referenced in the left column. One of the
Amami City, Contact (with passengers and one of the crew members
Kagoshima breakwater) were slightly injured, the bow was severely
Prefecture damaged, and the breakwater off the Naze
Port was damaged.

* The report included Remarks

9 Feb. 24, May 21, 2010 Cargo ship The cargo ship HARMONY WISH was
2012 Off the north of HARMONY WISH navigating westward towards Ningbo in the
Himeshima (Cambodia) People's Republic of China and the cargo
Island, Cargo ship ship SHINKAZURYU was navigating
Himeshima SHINKAZURYU eastward towards Fukuyama Port of
Village, Oita Collision Fukuyama City in Hiroshima Prefecture.
Prefecture Both ships were collided with each other in
the area referenced in the left column, in
which the visibility was restricted due to
fog. The HARMONY WISH sustained a
breach and a dent on her hull of starboard
bow and the SHINKAZURYU sustained a
bent-damage on the bulwark at her port bow
and a dent on her hull. But no fatality or
injury was caused on both ships.

* The report included Remarks

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Date of
No. Date and Location Name of Accident Summary
publication
10 Feb. 24, July 24, 2010 Motor boat The boat running in the Shikama Section 1
2012 Shikama Section CAPRICORN of Himeji Port contacted with the Shikama
1 of Himeji Port, Contact (with East Breakwater. The master was injured
Himeji City, breakwater) and the bow was crushed.
Hyogo
Prefecture * The report included Remarks
11 Feb. 24, Aug. 18, 2010 Cargo ship STAR While the ship mooring at the pier
2012 Hattaro P Pier of KVARVEN referenced in the left column was
Hachinohe Port, (Norway) discharging its cargo, a stevedore fell from
Hachinohe City, Fatality of a either a hatch cover on the cargo hold or the
Aomori stevedore maintenance ladder at the foot of the gantry
Prefecture crane. The stevedore was taken to the
hospital, but was later pronounced dead.

* The report included Remarks

12 Mar. 30, Aug. 15, 2010 Personal water craft An operator who did not have license for
2012 Kusuhama (unnamed) personal watercraft was wandering off the
Seashore of Injury to swimmers Kusuhama seashore on the watercraft, and
Mitoyo City, the operator fell in the water but kept
Kagawa running the watercraft only with the left
Prefecture hand, resulting in the contact with two
swimmers who were walking back to the
sandy beach. They were injured.

* The report included Remarks

13 Mar. 30, Aug. 28, 2010 Motor boat SAN The boat returning to her marina in
2012 Kanazawa Port, Contact (with Kanazawa Port contacted with the sediment
Kanazawa City, sediment control control groin in the Port. The skipper and
Ishikawa groin) two co-passengers were injured and the
Prefecture starboard bow was breached.

* The report included Remarks

14 Mar. 30, Apr. 5, 2011 Recreational fishing The skipper, while adjusting the anchoring
2012 Off the vessel KAIRIN position in the fishing spot in the area
west-southwest MARU referenced in the left column, was caught on
of Hinomisaki, Fatality to a crew his right ankle by the anchor rope and fell in
Mihama Town, member and a the sea. One passenger trying to prevent the
Wakayama passenger skipper from falling also fell in the sea. Both
Prefecture of them were killed.

* The report included Remarks

15 Apr. 27, June 13, 2009 Cargo ship While the ship was berthed at the wharf
2012 Raw Material SINGAPORE GRACE referenced in the left column, one of the
Acceptance (Hong Kong) workers fell while descending a ladder in
Wharf (Hiroura Fatality of workers No. 3 cargo hold for cargo work. Two of the
A wharf), Nikko three other workers who went to rescue him
Smelting & also collapsed in the cargo hold. The all
Refining Co., three workers were rescued from No. 3 cargo
Ltd., Saganoseki hold, but later they were confirmed dead.
Smelter and
Refinery, wharf * The report included Recommendations,
of port of Opinions, Safety Recommendations and
Saganoseki, Oita Remarks
City, Oita
Prefecture

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Date of
No. Date and Location Name of Accident Summary
publication
16 May 25, Nov. 15, 2010 Passenger ferry The passenger ferry FERRY KITAKYUSHU
2012 Traffic Route in FERRY and chemical Tanker KOKI MARU No. 78,
Kurushima KITAKYUSHU both of which were navigating
Strait Chemical Tanker southeastward on the Traffic Route in the
KOKI MARU No. 78 Kurushima Strait, collided with each other
Collision around the north exit of the West Suido
Channel of the Route. The FERRY
KITAKYUSHU sustained a dent on the
starboard stern, and KOKI MARU No. 78
did on the port bow, but no fatality or injury
was caused on both vessels.

* The report included Remarks

17 May 25, June 12, 2011 Cargo ship The cargo ship DAISENZAN MARU
2012 Northwest of DAISENZAN MARU navigating southwestward from Keihin Port
Oshima Island, Recreational fishing and the recreational fishing vessel HISA
Oshima Town, vessel HISA MARU MARU drifting and angling in the area
Tokyo Collision referenced in the left column collided with
each other. One of the passengers on the
HISA MARU was injured and her starboard
was cracked. The DAISENZAN MARU
sustained scratches on the bow.

* The report included Remarks

18 May 25, July 2, 2011 Recreational fishing While navigating toward Nakaminato Port
2012 East breakwater vessel KAMOME under the restricted visibility condition due
outside of MARU to dense fog, the vessel contacted with the
Nakaminato Contact (with breakwater referenced in the left column.
Port located in breakwater) Twelve passengers were injured and the bow
Hitachinaka and bulbous were damaged.
City, Ibaraki
Prefecture * The report included Remarks

19 June 29, June 9, 2010 Commuter boat The boat grounded on the Uose Reef
2012 Uose Reef, off FRESH ARIKAWA northwest of Enoshima Island when she was
the northwest of Grounding navigating westward off the north of
Enoshima Kanagashirase Reef in Saikai City after
Island, Saikai leaving the Sasebo Port of Sasebo City for
City, Nagasaki Arikawa Port of Shinkamigoto Town, both
Prefecture ports in Nagasaki Prefecture. The passenger
and master of the boat were injured, she
sustained a breach and a dent on her bottom
and propeller shaft and blades were bent.

* The report included Remarks

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Date of
No. Date and Location Name of Accident Summary
publication
20 June 29, July 1, 2010 Cargo ship The cargo ship SHINKENWA MARU was
2012 Off the north of SHINKENWA MARU navigating south-southeastward towards
Naruto Strait Cargo ship SHOWA the Naruto Strait and the cargo ship
MARU No. 8 SHOWA MARU No. 8 was navigating
Collision north-northwestward after passing through
the Naruto Strait. Both ships collided with
each other in the area referenced in the left
column. One of crew members of the
SHOWA MARU No. 8 was injured and the
bow was breached and dented causing the
flooding in the cargo hold. The bow of the
SHINKENWA MARU was cracked and
dented causing the flooding in the forepeak
tank but no one was injured.

* The report included Remarks

21 June 29, Aug. 28, 2010 Motor boat SUZU The five co-passengers onboard the boat
2012 Naruto Strait Injuries to were injured when the boat navigating
co-passengers southward in the vicinity of the Onarutokyo
Bridge of the Naruto Strait was shaken up
and down. The boat sustained cracks on the
stern bulkhead and windshield.

* The report included Remarks

22 June 29, Oct. 16, 2010 Cargo ship DAIKO The ship grounded on the rock reef of the
2012 Seashore, MARU seashore referenced in the left column, when
Northeast of Grounding she was navigating northwestward off the
Kuji Port, Kuji Kuji Port. The entire hull of her bottom was
City, Iwate breached and cracked causing the flooding
Prefecture but no leakage of fuel oil and others was
observed. There was no casualty to her crew.

* The report included Remarks

23 June 29, Oct. 27, 2010 Fishing vessel The fishing vessel DAIKO MARU leaving
2012 Off the DAIKO MARU Tomo Port of Fukuyama City in Hiroshima
southeast of Fishing vessel Prefecture for Hashirijima Port of the same
Sensuijima MIYAJIMA MARU city was navigating southeastward and the
Island, Collision fishing vessel MIYAJIMA MARU was
Fukuyama City, drifting. The both vessels collided with each
Hiroshima other in the area referenced in the left
Prefecture column. One of crew members onboard the
MIYAJIMA MARU fell in the sea and was
drowned. The vessel sunk due to the damage
on the port mid-section. The bow paint on
the DAIKO MARU was scaled off but no one
was injured.

* The report included Remarks

24 July 27, Mar. 21, 2010 Cargo ship When weighing the anchor of the ship in the
2012 Off the Ichikawa TSURUYOSHI area referenced in the left column, the chief
Passage, Chiba MARU No. 3 officer on the forecastle deck was hit, fell
Port, Chiba Injury to a crew down and injured by the green water.
Prefecture member
* The report included Remarks

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Date of
No. Date and Location Name of Accident Summary
publication
25 July 27, June 20, 2010 Cargo ship SEIREI The cargo ship SEIREI MARU was
2012 Off the east of MARU navigating southwestward in the Akinada
Aijima Island, Cargo ship GYOREN from the west entrance of the Kurushima
Matsuyama 1 Strait Traffic Route to the Kudako Channel
City, Ehime Collision west of Nakajima in Matsuyama City and
Prefecture the cargo ship GYOREN 1 was navigating
northeastward from the Kudako Channel to
the west entrance of the Kurushima Strait
Traffic Route. Both ships collided with each
other in the area referenced in the left
column. The SEIREI MARU sustained the
dent damage in her port bow and the
GYOREN 1 did the damages on the hull and
handrails on the port mid-section. But no
fatality or injury was caused on both ships.

* The report included Remarks

26 July 27, Jan. 11, 2011 Cargo ship EN KAI While the ship was berthing at the berth
2012 Around South (China) referenced in the left column, a tensed
Berth A, Fatality to crew mooring rope suddenly bounced and struck
Funabashi Chuo members on the chest of a boatswain working on the
Wharf, forecastle deck. The boatswain, taken into
Katsunan the hospital, died despite medical
District, Chiba treatment.
Port, Chiba
Prefecture

27 July 27, Mar. 18, 2011 Motor boat The motor boat YOSHIOKA MARU was
2012 Katakami Port, YOSHIOKA MARU running eastward from the Katakami Port
Bizen City, Racing boat to the fishing spot and the racing boat
Okayama (unnamed) (unnamed) was being rowed westward. Tow
Prefecture Collision boats were collided with each other in the
Katakami Port. One of the oarsmen was
injured and the boat was -broken on her
stern and capsized. The YOSHIOKA MARU
sustained scratches on the port bow and
other places but no fatality or injury was
caused on her.

* The report included Remarks

28 Aug. 31, Jan. 4, 2011 LNG bulk carrier The carrier navigating northward in the
2012 Nakanose RYOAN MARU Nakanose Traffic Route toward the Chiba
Traffic Route Contact (with a light Port in Chiba Prefecture, collided with No. 1
Light Beacon No. beacon) light beacon on the Traffic Route. The
1, Nakanose carrier sustained the dent and other
Traffic Route of damages on the hull of her starboard bow
Tokyo Bay but no fatality or injury was caused. The No.
1 light beacon on the Nakanose Traffic
Route was crushed on its platform.

* The report included Remarks

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Date of
No. Date and Location Name of Accident Summary
publication
29 Aug. 31, Dec. 1, 2010 Pure car carrier While car carrier loading cars at the wharf
2012 Nissan Motor VEGA LEADER referenced in the left column, a deck panel
Honmoku Wharf, (Panama) of car deck No. 7 fell down onto car deck No.
Yokohama Injuries to 6. Six stevedores in cargo operation on the
Section 5 of longshoremen deck panel and four stevedores on car deck
Keihin Port No. 6 immediately below the panel, ten
persons in total, were injured.

* The report included Safety

Recommendations and Remarks

30 Aug. 31, Nov. 24, 2010 Passenger ship One of passengers on the upper deck
2012 Upstream side of RYOMA passenger room were injured when the
Sumidagawa Injury to a passenger windows of the room were remotely opened
Bridge on while the ship was moving down the river in
Sumidagawa the vicinity of the bridge referenced in the
River, left column.
Toubu-Isesaki
Line, Sumida * The report included Remarks
Ward, Tokyo
31 Sept. 28, Mar. 18, 2010 Cargo ship MEDEA The cargo ship MEDEA was navigating
2012 Off the South (Singapore) southwestward off the southwest of the East
Mouth of East Fishing vessel KOSEI Channel of the Nagoya Port toward the
Channel, Nagoya MARU vicinity of the Irago Channel North
Port, Aichi Collision Entrance, and the fishing vessel KOSEI
Prefecture MARU was navigating westward off the
west of Isewan Bay Light Beacon toward the
fishing area north of the Isewan Bay. The
ship and vessel collided with each other in
the area referenced in the left column. The
skipper and a crew member of the KOSEI
MARU were injured and she capsized. The
MEDEA sustained scratches on her bow.

* The report included Remarks

32 Sept. 28, June 28, 2011 Chemical tanker On the tanker navigating in the North
2012 North Channel NISSHO MARU Channel of Nagoya Port, three (chief officer,
of Nagoya Port, Fatality and injury to second engineer, and junior chief officer) of
Aichi Prefecture crew members four crew members cleaning the tank fell
down on the starboard side of the forecastle
deck, and the remaining one (chief engineer)
was in the clouded consciousness at the
stern. The chief officer and second engineer
were confirmed dead. The junior chief officer
and chief engineer were injured.

33 Sept. 28, July 7, 2011 Chemical tanker In the tanker navigating northward from
2012 Around the HOTOKU MARU Chiba Port to the anchorage in the vicinity
mouth of Injury to a crew of Umihotaru Parking area on the Tokyo
Sodegaura member Bay Aqua Line, the second engineer found
channel, Chiba an engine rating unconscious in the ballast
Section of Chiba pump room. The engine rating was rescued
Port, Chiba and recovered from unconsciousness.
Prefecture

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Date of
No. Date and Location Name of Accident Summary
publication
34 Oct. 26, 2012 Sept. 7, 2011 Fishing vessel The fishing vessel KASHIMA MARU No. 18
Off the KASHIMA MARU was drifting the area referenced in the left
southeast of No. 18 column and the fishing vessel TAIKO
Cape Nosappu, Fishing vessel MARU No. 58 was navigating southward in
Nemuro City, TAIKO MARU No. 58 the same area. Two vessels collided with
Hokkaido Collision each other. Two of deckhands in the fishing
Prefecture vessel TAIKO MARU No. 58 were injured
and the vessel sustained the dent and other
damages on her bow. The fishing vessel
KASHIMA MARU No. 18 sustained a breach
on her stern but no one was injured.

35 Nov. 30, Aug. 25, 2010 Personal watercraft Both of the operator and co-passenger on the
2012 Unknown IKARUGA watercraft departing the Tanomohama
(Offing of Missing of skipper Shore fell in the water between the
Tanomohama east-northeast and east off the Shore, and
Shore, the operator sunk in the water and went
Inawashiro missing. The co-passenger was rescued by
Lake, the personal watercraft coming for help, and
Aizuwakamatsu the watercraft IKARUGA was not damaged.
City, Fukushima
Prefecture)

36 Nov. 30, Mar. 22, 2010 Fishing vessel When the fishing vessels KAISHO MARU
2012 Off the west of KAISHO MARU and FUKUJU MARU collided with each
Omaezaki, Fishing vessel other in the area referenced in the left
Omaezaki City, FUKUJU MARU column when the KAISHO MARU was
Shizuoka Collision heading at about 290° while searching a
Prefecture school of fish and the FUKUJU MARU was
heading about 110° after completing the
port turn to turn her around. Three crew
members (one deckhand of the KAISHO
MARU, skipper and deckhand of the
FUKUJU MARU) were killed, and four
members (skipper of the KAISHO MARU
and three deckhands of the FUKUJU
MARU) were injured. The KAISHO MARU
was severely damaged and the FUKUJU
MARU capsized.

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Date of
No. Date and Location Name of Accident Summary
publication
37 Nov. 30, Apr. 9, 2010 Cargo ship RYUNAN The cargo ship RYUNAN II was navigating
2012 Off the II southward off the Nomozaki toward Naha
southwest of Recreational fishing Port in Okinawa Prefecture, and the
Nomozaki, vessel KOYO MARU recreational fishing vessel KOYO MARU
Nagasaki City, Collision was navigating south-southwestward
Nagasaki toward Ajisone fishing spot off the
Prefecture Nomozaki. The port bow of the RYUNAN II
and the starboard section of the KOYO
MARU were collided with each other,
causing the KOYO MARU capsized. The
skipper and one of the passengers on the
KOYO MARU went missing and two of the
passengers were injured. Later on, the
skipper and one passenger were removed
from their family register per the
posthumous recognition of their death. On
the KOYO MARU, the wheel house and
upper structure of the cabins were damaged
and the starboard hull was bent. The
RYUNAN II sustained scratches on her bow
but no one was injured.

38 Nov. 30, June 29, 2011 Diving boat YDS VII While helping out the surfaced instructor
2012 Off the Injury to an and divers get on the boat in the area
northwest of instructor and diver referenced in the left column, the instructor
Umabanasaki, and one of divers contacted with propeller
Yonaguni Town, blades and other fittings and the both of
Okinawa them were injured.
Prefecture
* The report included Remarks

39 Nov. 30, Sept. 19, 2011 Tug boat KITA The boat capsized when she, together with
2012 In Wajima Port, MARU No. 12 the tugboat KITA MARU No. 8, was towing
Wajima City, Capsizing the patrol boat MIURA for her departure
Ishikawa from the port. Two of the crew members on
Prefecture the boat were rescued but all of them were
killed. Later on, the boat was salvaged but
declared a total loss.

* The report included Recommendations

40 Dec. 21, Oct. 24, 2010 Oil tanker When the tanker was berthing at the berth
2012 No.1 Berth for PACIFIC POLARIS referenced in the left column under the
Nansei Sekiyu (Panama) command of the master supported by the
K.K, Contact (with a berth) berth master, she contacted with the
Kin-nakagusuku dolphin of the berth. The tanker sustained a
Port, Okinawa breach on the port stern making the fuel oil
Prefecture leak out of No.2 port side fuel oil tank and
making the dolphin structure deformed. But
no one was injured.

* The report included Remarks

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Date of
No. Date and Location Name of Accident Summary
publication
41 Dec. 21, Jan. 9, 2011 Chemical tanker The tanker capsized and sank in the sea
2012 Off the SEIYO when it was navigating east-northeastward
southwest of Foundering from an anchorage off the Oita Airport in
Sadogashima Oita Prefecture to the Akadomari Port in
Island, Sado Sado City (Sado Island), Niigata Prefecture
City, Niigata by way of off the Rokkosaki in Suzu City
Prefecture (Noto Peninsula), Ishikawa Prefecture. The
chief engineer was killed and the master
went missing.

42 Dec. 21, Aug. 17, 2011 Passenger boat The boat cruising down the Tenryugawa
2012 Tenryugawa TENRYU MARU No. River grounded on the rocks on the left bank
River, Futamata, 11 of the River and capsized, leaving four
Tenryu Ward, Capsizing passengers and a skipper dead and five
Hamamatsu passengers injured.
City, Shizuoka
Prefecture

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9. Summaries of recommendations and opinions

There were six recommendations, four opinions, and two safety recommendations in 2012,
which are summarized below:

(1) Recommendations (Six cases)

1) In view of the results of the accident investigation of fatality of workers on the cargo ship
SINGAPORE GRACE on April 27, 2012 the Japan Transport Safety Board (the JTSB)
recommended the Saganoseki Smelter & Refinery, Pan Pacific Copper Co., Ltd. to take the
following measures for the purpose of prevention of accident caused by oxygen-deficient in
cargo hold.

(1) To train all employees who have the possibility of being engaged in cargo work to understand
the properties and risks of copper sulfide concentrate.
(2) To train all employees, who have the possibility of being engaged in cargo work, with the
handling of O2 meters in order to measure O2 concentrations as necessary.
(3) To request the MSDS of floatation reagents from shippers.
(4) To inform employees who have the possibility of being engaged in cargo operation on the
following:
[1] Depending upon the properties of the floatation reagent adhered to copper sulfide
concentrate, it may generate toxic gas.
[2] Since the generated toxic gas is heavier than air, it stagnates in cargo hold; hence, there is
a danger of not being replaced by air.
(5) To make the risks of oxygen-deficient conditions and anoxia known to all personnel who have
the possibility of being engaged in cargo operation and to familiarize them with appropriate
coping behavior in case of fatal accidents occurring in cargo holds loading copper sulfide
concentrate.

2) In view of the results of the accident investigation of fatality of workers on the cargo ship
SINGAPORE GRACE, on April 27, 2012 the JTSB recommended the Nissho Koun Co., Ltd., to
take the following measures for the purpose of prevention of accident caused by
oxygen-deficient in cargo hold.

(1) To train all employees who have the possibility of being engaged in cargo operation to
understand the properties and risks of copper sulfide concentrate.
(2) To train all employees, who have the possibility of being engaged in cargo work, with the
handling of O2 meters in order to measure O2 concentrations as necessary.
(3) To make the risks of oxygen-deficient conditions and anoxia known to all employees who have
the possibility of being engaged in cargo operation and to familiarize them with appropriate
coping behavior in case of fatal accidents occurring in cargo holds loading copper sulfide
concentrate.

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3) In view of the results of the accident investigation of the capsizing of the cutter (unnamed), the
JTSB gave recommendations to the Shogakukan-Shueisha Productions Co., Ltd. for the safety
of activities related to the cutter training at Shizuoka Prefectural Mikkabi Youth Center on
January 27, 2012 as follows.

(1) The criteria for cutter training suspension and the cutter training methods used at the
Shizuoka Prefectural Mikkabi Youth Center should be reviewed to ensure their adaptability
based on the experience of the trainees, and the following provisions should be included in the
instruction manual:
a. The criteria for suspending training when weather advisories are broadcast.
b. The criteria for suspending training under bad weather other than when weather
warnings or advisories are broadcast.
c. Training methods under bad weather
d. The time for deciding the permission or no of training and the time (including a time
during training) for deciding a training method.
e. Treatment of training if suspended on its way
f. Measures for safety in training (including the arrangement and duty of a guard boat,
constant contact with weather information, and preparations for the tow of cutter)
(2) A rescue system, supposing cutter accidents and including procedures for towing and
rescuing a cutter, should be established, and the Youth Center personnel should be
periodically trained. Effort should be made to strengthen cooperation with rescuing agencies.
(3) Effort should also be made to improve the knowledge of the Youth Center personnel with
respect to cutter and weather, and to inspire their consciousness of ensuring safety of training.

4) In view of the results of the accident investigation of the capsizing of the cutter (unnamed), the
JTSB gave recommendations to the Shizuoka Prefectural Board of Education for the safety of
activities related to the cutter training at Shizuoka Prefectural Mikkabi Youth Center on
January 27, 2012 as follows.

The Board should review the criteria for training suspension, the training methods, and
the crisis management manual of the Youth Center, should give them necessary corrections, if
found any, and should have tow training practiced.

5) In view of the results of the accident investigation of capsizing of the tug boat KITA MARU No.
12 the JTSB recommended the Japan Coast Guard School to take the following measures for
the purpose of ensuring the safety navigation of the MIURA on November 30, 2012.

In view of the fact that the Japan Coast Guard School has been accepting the MIURA
every year as training ship, the School is recommended to define clear organization managed by
the school principal to carry out safe onboard sea training on the MIURA, and to establish the
comprehensive management system for ensuring; to prevent accidents and give safety guidance
under normal circumstances; to share such information required for the safe
navigations/operations as metrological and navigational warning information; to understand

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the operational status of the MIURA when she is on the training mission; and to secure
communications and support in case of emergency.

6) In view of the results of the accident investigation of capsizing of the tug boat KITA MARU No.
12 the JTSB recommended Kita-Gumi Co., Ltd. to take the following measures for the purpose
of ensuring the safety of the towing the vessel with the tug boat on November 30, 2012.

The Kita-Gumi Co., Ltd. is recommended to take the following actions to ensure the safety
of towing operations with its boat:
(1) To check and maintain towing hooks and to perform its operation training.
(2) To instruct the crew members to wear such outfits as lifejacket properly during the towing
operations.

(2) Opinion (four cases)

1) In view of the results of the accident investigation of fatality of workers on the cargo ship
SINGAPORE GRACE, on April 27, 2012, the JTSB expressed its opinions to the Minister of
Land, Infrastructure, Transport and Tourism for the purpose of prevention of recurrence of
similar accidents as follows.

The Board requests the Minister of Land, Infrastructure, Transport and Tourism to widely
disseminate following information regarding the risks of the use of floatation reagents through
the International Maritime Organization (IMO).
(1) Depending upon the properties of the floatation reagent adhered to copper sulfide
concentrate, it may generate toxic gas.
(2) Since the generated toxic gas is heavier than air, it stagnates in cargo hold; hence, there is
a danger of not being replaced by air.

2) In view of the facts of the foundering of the chemical tanker SEIYO, on June 29, 2012 the JTSB
expressed its opinions to the Minister of Land, Infrastructure, Transport and Tourism for the
purpose of prevention of recurrence of similar accidents as follows.

When the vessel with low freeboard is navigating under the condition where the green
water hits onto the expansion trunk, the waves hit the upper deck and expansion trunk causing
the sea water to remain on the ship. It may sometimes make the vessel to list and the sea water
to flow into the ballast tank through the air pipes on the upper deck. It is necessary that the
Minister is to instruct the vessel owner and operator to fully maintain the air pipe head.

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3) In view of the facts of the capsizing of the passenger boat TENRYU MARU No. 11, on April 25,
2012 the JTSB expressed its opinions to the Minister of Land, Infrastructure, Transport and
Tourism for the purpose of prevention of recurrence of similar accidents while going down a
river as follows.

(1) Anticipation of risks hidden in route

Route of a boat (rafting boat) going down a river can become potentially dangerous
when the river changes its condition such as the rising of the river. The rafting boat, if it is
improperly steered against the condition of the river, can be in the serious condition such as
grounding on rocks and the resultant capsizing.
The Tenryu Hamanako Railroad Co., Ltd. (hereinafter referred to as “the Corporation")
had been making an effort to inform the skippers of such information as potentially
dangerous points on the rafting route as well as cautions in steering the boat, however an
system was not established to share the recognition of the situation in which an accident
could occur in the route when the boat is turned.
It is desirable for the similar operators of the rafting boat (hereinafter referred to as
“the Rafting boat operators") throughout the country to recognize the risks in the route they
are operating in order to further increase the safety in operating the rafting boat; to establish
the system to study proper steering method in case of situation that could trigger an
accident; to do necessary studies; and to share among skippers and operation managers the
results of the studies including the risk assessments in the route. In order to fulfill the above,
the Minister of Land, Infrastructure, Transport and Tourism is to instruct the Rafting boat
operators throughout the country to identify the risks in the route; to study proper steering
method in case of situation that could trigger an accident, and to share among skippers and
operation managers the results of the studies including the risk assessments.

(2) Provision and wearing of lifesaving outfits, and explanation of how to use them
The Corporation has equipped the boats with lifesaving cushions and lifejackets as the
lifesaving outfits for the passengers but most of passengers and skippers could not grab the
lifesaving cushions when they fell in the river, and the children including one infant did not
wear the lifejacket. Also note that the Corporation did not equip the boats with the lifejacket
suitable for the infant whose weight is 15 kg or less. It is probable that all of these matters
were related with the worsening of the casualties.
Seven Rafting boat operators inspected last year was confirmed that they were
equipped their boats with the appropriate lifesaving outfits and addressing to implement the
proper use of the outfits in line with the guidance given by the MLIT Maritime Bureau after
the occurrence of the accident. It is probable that other Rafting boat operators will also be
observing the same guidance.
Thus, the Minister of Land, Infrastructure, Transport and Tourism is to keep providing
the Rafting boat operators throughout the country with the guidance regarding the provision
and wearing of lifesaving outfits, and explanation of proper use of the outfits in order to
ensure the safety of the passengers and skippers.

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4) In view of the results of the marine accident investigation and other activities of the personal
watercraft, on March 30, 2012 the JTSB expressed its opinions to the Minister of Land,
Infrastructure, Transport and Tourism for the purpose of prevention of marine accident caused
by the personal watercraft as follows.

In view of the following occurrence situation of the marine accidents caused by the personal
watercraft (hereinafter referred to as “the Personal watercraft accident”), the Minister is to
make the importance of compliance to the maritime laws such as Act on Ships’ Officers and
Boats’ Operators (hereinafter referred to as “the Act”) well known to the operators and
organizations related with the watercraft operation, as well as the occurrence situation of the
Personal watercraft accident, and to give them guidance. Effort should continuously be made to
penetrate this matter and give safety guidance to small craft operators and others.

(1) The total of 126 Personal watercraft accidents occurred in 175 personal watercrafts, leaving
21 persons dead and 142 persons injured.
(2) Among the Personal watercraft accidents, the most common accident was the collision, the
number of which was 65, and the next common one was the injuries and others, the number of
which was 54. The sum of these two types of accident counted for about nine tenths or more
(about 94.4%) of the entire Personal watercraft accidents.
(3) In 17 Personal watercraft accidents in 20 watercrafts, the operator not having the License
was maneuvering the watercraft and resulted in an accident. Four operators died and nine
operators sustained such serious injuries as bone fracture.
(4) In 8 Personal watercraft accidents in 9 watercrafts, the operator did not observe the
stipulations in the Act and two operators died and 12 operators sustained injuries. They
violated such stipulations (i.e., matters to be observed) as Prohibition of drunken operation
and Operation only by the holder of the Small Vessel Operator License.
(5) In 6 Personal watercraft accidents in 6 watercrafts, the operator did not notice the
swimmer(s) swimming in the bathing beach or other place and hit the swimmer(s) with the
watercraft injuring 7 swimmers (In 2 accidents in 2 watercrafts the operator was not a holder
of the License).
(6) In 22 Personal watercraft accidents in 22 watercrafts, the person(s) on the floating body
such as rubber raft was killed or seriously injured while the watercraft was towing the floating
body. Two of the persons died and 11 of them sustained such serious injury as bone fracture.
The above-cited situations in which the Personal watercraft accident occurred are derived
from the Investigation Reports of marine accidents and incidents published from Oct. 2008 and
the end of March 2012.

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(3) Safety Recommendations (two cases)

1) In view of the results of the accident investigation of fatality of workers on the cargo ship
SINGAPORE GRACE, on April 27, 2012 the JTSB recommended the Ok Tedi Mining Limited
to take the following measures for the purpose of safe transportation and cargo operation by
making the properties of floatation reagents adhering to copper sulfide concentrate known to
the persons involved.

In case of the possibility of the existence of floatation reagents adhering to copper sulfide
concentrate, it is recommended to the Ok Tedi Mining Limited as the shipper to submit
information (Material Safety Data Sheet, etc.) on floatation reagents in addition to information
of copper sulfide concentrate (Material Safety Data Sheet, etc.) to ships and consignees in order
to make the properties and the risks of copper sulfide concentrate and floatation reagents known
to ships and consignees.

2) In view of the results of the accident investigation of Injuries to longshoremen of the pure car
carrier VEGA LEADER, on August 31, 2012 the JTSB recommended the owners and operators
of car carriers to take the following measures for the purpose of prevention of recurrence of
similar accidents.

It is somewhat likely that the accident occurred because, while VEGA LEADER (hereinafter
referred to as “the Ship”) was loading cars at Nissan Motor Honmoku Wharf, Yokohama Section
5, Keihin Port, car deck No. 7, not supported by the deck support at the starboard bow end, while
the loading of cars on the deck panel of cargo deck No. 7 (hereinafter referred to as “the Deck
Panel”) progressed, fell onto car deck No. 6, and the ten longshoremen working on the Deck Panel
or car deck No. 6 immediately below the Deck Panel were injured.
It is somewhat likely that the height of the Deck Panel, while the Ship was navigating to
Kanda Port, was readjusted from the middle position to the normal position, the Deck Panel was
lowered without anyone being aware that the deck support on its starboard bow end was neither
fully open nor in a state to support the Deck Panel, and the deck support on the starboard bow
end moved outward from the Deck Panel.
It is somewhat likely that the absence of stipulation by the management company in their
safety management manuals of work-procedures specifically describing the work for readjusting
the height of a deck panel and the Ship’s lack of systems for confirming the state of deck supports
by, for example, using a check list prior to lowering deck panels contributed to the occurrence of
the accident.
Therefore, it is necessary for owners and management companies of pure car carriers to
reconsider and work out measures for ensuring confirmation that deck supports are in a state to
correctly support a deck panel prior to lowering the deck panel and putting it on the deck support,
and in addition, instruct their crew members regarding such measures.
Based on the experiences of the accident, a measure for preventing a fall of a deck panel by
employing fixed-type deck supports was applied. Since ships are equipped with facilities and
other things that may cause a severe accident, involving injury, due to a crew member’s absence
of confirmation, ship owners in general and others should consider hardware-based safety

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measures for facilities as a lesson learned from the accident.

Therefore, it is most likely necessary for owners of car carriers to consider and employ safer
systems, such as fixed-type deck supports at the lowest level to prevent a panel-falling accident.

10. Remarks
The JTSB made remarks on the following 33 marine accidents in 2012.

1) Marine accident of grounding of cargo ship MIHARU MARU

(Published on January 27, 2012)
It is probable that this accident occurred as the result of the following series of events. When
this ship was navigating south southeastward off the northwest of Otate Island in the nighttime,
the first officer on the bridge watch turned the heading about 070° to make the ship pass the
north of the Island and then the officer turned the heading in clockwise for three times to make
the heading be between 092° and 107°. During these three maneuvers, the officer did not check
the ship position against the chart or with any other tools or means, and the officer did not
foresee the ship's approach to the Irose Reef after these maneuvers. Thus, the officer kept the
ship staying on the course without noticing that the ship was on the course approaching the Reef
finally making the ship grounded on the Reef.
The following measures to avoid the recurrence of this accident are conceivable:
(1) The relieving officer on bridge watch, prior to his duty, is to check such conditions as shallow
waters near the planned course in addition to the ship's position, heading, and speed.
(2) The officer on bridge watch is to follow the planned course instructed by the master. If the
officer is going to change the planned course to new course, the approval from the master is
required.
(3) The officer on bridge watch, prior to heading change, is to check the ship's position as well as
such conditions as shallow waters near the new course.
(4) The officer on bridge watch is to be always and properly watchful by making full use of all the
tools suitable for the situation such as the radar and GPS plotter in addition to visual lookout.
(5) The master and crew member(s) on duty on the bridge is expected to be daily aware of keeping
good communications among themselves on the bridge by making use of the technique used in the
BRM so that the shearing of such important navigational information as the course can become
common practice.

2) Marine accident of contact (with breakwater) of cargo ferry NANKAI MARU No. 3
(Published on January 27, 2012)
It is probable that this accident occurred as the result of the following series of events. The
master did not check the ship's position with the radar while the ship was navigating southward
in the Naze Port in the nighttime, and kept navigating the ship without noticing that the ship
was heading toward the breakwater off the Port, resulting in the collision with the breakwater.
It is probable that since the master was keeping an eye on a fishing boat navigating
oppositely on the portside, the master failed to check the position with the radar.
The following measures to avoid the future recurrence of the similar accident are
conceivable:

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(1) Make sure to locate the ship's position with the radar and to understand the position relative
to the breakwater.
(2) When navigating in the port, reduce the ship speed early enough to be able to have sufficient
lead time to change the course near the breakwater and in preparation for the case where the
ship cannot keep the planned course due to an encounter with other ship.

3) Marine accident of collision between chemical tanker SAMHO HERON and cargo ship
GOLDEN WING
(Published on January 27, 2012)
It is probable that the chemical tanker SAMHO HERON and cargo ship GOLDEN WING
collided with each other because the crew on both vessels did not conduct lookout off the
southwest of Kajitori-no-Hana in the nighttime while SAMHO HERON was navigating
northeastward on the left side of Akinada South Traffic Route centerline and GOLDEN WING
was navigating southwestward on the right side of the same centerline.
In the Seto Inland Sea, the recommended routes are designated in major Traffic Routes
even though the law does not designate them. At the center of the recommended routes there are
light beacons installed and it has been penetrated among the vessels navigating on the
recommended route to use the right side of the route centerline.
In this accident, the SAMHO HERON resulted in facing with multiple vessels including
GOLDEN WING that were navigating the right side of the centerline because the SAMHO
HERON was navigating the left side of the centerline, which caused the collision with the
GOLDEN WING. In order to avoid the recurrence of the accident, it is expected for the vessels
navigating on the recommended route to use the right side of the centerline.

4) Marine accident of flooding of passenger ship KASHIMA

(Published on January 27, 2012)
It is somewhat likely that this accident occurred as the result of the following series of
events. Those who were involved in repairing the leak from the shaft seal device did not push
back the wedge ring evenly, and in addition they did not retighten the locking bolts of the device
after the test run of the engine. Vibrations caused by engine operations after the test displaced
the wedge ring; loosened the locking bolt(s); made the shaft seal device leak water; and finally
made water flooded in the engine room.
Those who inspect and maintain the shaft seal device is to follow such prescribed procedures
as the use of the positioning gauge in maintaining the device and retightening of the locking bolts
of this device after the engine test run. The crew members who inspect the engine section are to
observe the maintenance and inspection manual; to periodically inspect the conditions of the
locking bolts and shaft seal device for any leakage; and to visually inspect the bilge water level in
the engine room.
The operation manager is to recognize the importance of properly inserting the packing
materials in the emergency gland packing section in preparation for such serious situation as the
flooding and foundering caused by a lot of water leaked out of the end-face seal of the shaft seal
device.

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5) Marine accident of collision between cargo ships TY EVER and LOFTY HOPE
(Published on January 27, 2012)
Around Kanmon-kyo Bridge above the Kanmon Passage, the cargo ship TY EVER
navigating eastward was approaching another preceding vessel in the same direction when the
cargo ship LOFTY HOPE was navigating against the TY EVER from the opposite direction. The
TY EVER made an evasive left turn to avoid another vessel, which made her to collide with the
LOFTY HOPE.
Since the Kanmon Strait becomes narrowest around the Kanmon-kyo Bridge, which is the
position of this accident, the current gathers speed. If the eastbound preceding vessel is
navigating near to the center of the route and the following vessel is navigating near to the
sideline of the route, which is the Moji side of the Strait while the current is westbound, the
preceding vessel loses its speed as it approaches nearer to the Bridge making the following vessel
apt to approach near to the preceding vessel. This is because that in the center of the route west
of the Bridge the current has faster speed than the speed along the sideline of the route in the
Moji-side of the route.
Therefore, it is most likely necessary for a vessel, when navigating eastward in the west side
of the Bridge against the westbound current, to be watchful for the speed change of and distance
to the preceding vessel; to keep the safe distance to the preceding vessel as far as possible
navigating the South (Dead astern) of the preceding vessel so that she will not be in parallel with
or overtake the preceding vessel; and to navigate the right side of the Kanmon Passage along the
route.

6) Marine accident of collision between cargo ships WIEBKE and MARINE PEACE
(Published on January 27, 2012)
It is probable that this accident occurred as the result of the following series of events. Off
the Mojisaki at the Hayatomono-seto of the Kanmon Passage in the nighttime when the current
was westbound at about 5 kn, the cargo ship WIEBKE was navigating north-eastward along the
center of the Passage and cargo ship MARINE PEACE was navigating also north-eastward along
Moji-side of the Passage. When the MARINE PEACE was going to take over the WIEBKE from
the WIEBKE's starboard quarter, the bow of the MARINE PEACE encountered the current-rip
across which the current speed changed significantly, and the strong current hit on the starboard
bow that made the MARINE PEACE turn left, causing the MARINE PEACE proceed near to the
WIEBKE navigating the portside. The both ships collided with each other.
The speed of westbound current along the Moji-side of the Passage is lower than the current
speed at around the center of the Passage. Just like as this accident, a vessel navigating eastward
at Hayatomono-seto off the Mojisaki in the Passage along the Moji-side of the Passage may
sometimes approach another vessel navigating eastward along the center of the Passage;
navigate in parallel with; and takeover another vessel.
When a vessel is navigating eastward off the Mojisaki in the Passage under this situation,
the vessel encountering the current-rip is hit on her bow by the strong current and is made to
turn her bow to the left. It should be noted that the more the speed difference across the rip is, the
more severely the vessel is turned left, which poses the danger of approaching and colliding with
another vessel navigating along the center of the Passage.
Since in the night time, it is hard for a vessel to identify the current-rip(s) off the Mojisaki, it

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is most likely necessary for a vessel, to the maximum extent possible, to navigate dead astern of
the preceding vessel while keeping the safe distance from the preceding vessel, and to be carefully
controlled while properly watching the preceding vessel in preparation for the possible slowdown
and/or course change of the preceding vessel that may encounter the current-rip.

7) Marine accident of contact (with revetment) of motor boat QUEEN III

(Published on January 27, 2012)
It is probable that this accident occurred as the result of the following series of events. When
the skipper of this boat navigating southwestward off the southeast of the Tokyo International
Airport in the nighttime stopped operating the radar and started changing the monitor window to
display the GPS plotter image on the entire window, the skipper without knowing the signs
indicating the construction area of the Airport runway D were flushing red concentrated on the
window selection. Because of this concentration, he took the red flushing light from light beacon
A of the south construction area observed to his starboard as the red flushing light of the No. 2
light beacon showing the entrance to the Kawasaki Passage, and he began to steer the boat to the
right to enter the Passage. However he did not notice that the boat was running toward the
revetment because he still kept manipulating the monitor to change the window, and finally the
boat collided against the revetment.
It is most likely necessary for skippers navigating a small vessel in the nighttime within the
port even if navigating in the familiar area to study and confirm the navigation aids on the
planned route prior to departure and to concentrate on the watch and steering while navigating
the boat.

8) Marine accident of capsizing of cutter (unnamed)

(Published on January 27, 2012)
It is probable that this accident occurred as the result of the following series of events.
Under rainy weather of which heavy rain, thunder, gale, high-wave and flood advisories had been
forecast, the cutter was used for an outdoor activity at the junior high school of the Youth Center
and was engaged in a cutter rowing training without a trainer along an east course, which is a
usual way of the training, off the north shore of Lake Hamana. The gale and waves grew stronger
to render the rowing difficult, and the director of the Center went for rescuing on a motor boat,
and towed the cutter in a portside-inclined state and also in a subsequent state of continuous
inflow of lake water thereinto from the portside bow. When being towed in those states
southwestward off the south of Sakume, the cutter's leftward inclination sharpened under
increasing flowed-in water accumulation on her bottom and caused the portside oars to catch
water and to turn her stem leftward. Sometime later, the students sitting on the starboard side
lost balance and were shifted toward portside, to further increase the leftward inclination.
Consequently, the portside gunwale submerged, lake water flooded into the cutter, and finally
the cutter overturned portside.
It is most likely necessary for the local authorities having the facilities available for cutter
training to review their rescue system, procedures, etc. against the cutter accident. The system
should include a criteria to suspend the training when the weather warming/advisory is forecast;
cutter training method; and procedure for towing a cutter. It is also necessary for the local
authorities to take necessary actions if any problems found in the system; to enhance cooperation

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with rescuing agencies; and to give the staff of the facilities trainings for cutter accidents,
including a procedure for towing the cutter.
It is most likely necessary that when the local authorities entrust the management and
operation of the cutter training facilities to the designated managers, they should make the said
designated managers establish the rescue system, procedures, etc. against the possible cutter
accidents including cutter towing procedure; run the cutter towing training; and establish
cooperation with rescuing agencies.

9) Marine accident between cargo ships HARMONY WISH and SHINKAZURYU

(Published on February 24, 2012)
It is probable that this accident occurred as the result of the following series of events. When
the cargo ships HARMONY WISH and SHINKAZURYU detected each other ahead the beam of
the ship only with the radar while they were navigating off the north of Himeshima Island in the
limited visibility condition due to fog, they did not properly judge that both of them could
dangerously approach the other ship or that both of them could collide with each other. Because
of this improper judgment, both ships collided.
In view of the results of this accident investigation, it is most likely necessary to observe the
following items in order to avoid the recurrence of the accident similar to this accident:
1. Fundamental actions to be taken in limited visibility condition
While navigating in the water area where the visibility is limited or around that area,
the fundamental actions to be taken are to turn on lights required by law; blast the acoustic
signal (fog signal); and navigate at the speed appropriately safe in such conditions as
visibility and others.
2. Proper lookout
In the limited visibility condition, the crew member(s) is to always keep lookout in an
appropriate manner by making use of eyes, ears, AIS information, VHF communications,
and any other means in addition to the radar. The crew member is to try to detect other
vessels as early as possible by alternating the radar range between long and short ranges.
3. Proper judgment of other vessels
The vessel, when she detects other vessel(s) only with the radar, is to properly judge if
she could dangerously approach other vessel(s) or not, and if she could collide with other
vessel or not by observing the image of the said other vessel(s) methodically.
4. Maneuver to avoid such events as dangerous approach
When it is decided that the vessel could dangerously approach other vessel navigating
ahead the beam of her or she could collide with other vessel, she is to take the evasive
maneuver to avoid such events as above sufficiently earlier than the possible time of the
event. In case of the evasive maneuver, the vessel is not to turn left unless it is absolutely
necessary to make left turn.
5. Significant deceleration of vessel or bringing of vessel to stop
If a vessel cannot avoid getting too close to other vessel navigating ahead the beam of
her, the vessel should reduce her speed to the minimum that can keep the course or should
stop if necessary. In this case, the vessel should very carefully navigate until there is no
longer any fear of the collision.

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10) Marine accident of contact (with breakwater) of motor boat CAPRICORN

(Published on February 24, 2012)
This accident was caused by the following series of events. While this boat was running back
to her marina in Kobe City in the nighttime in the Shikama Section 1 of Himeji Port off the north
of the lighthouse on the Shikama East Breakwater, the skipper did not confirm the boat's
position when setting the course toward the entry of the Port. Therefore, he kept the boat running
without noticing that the boat was heading to the East Breakwater and the boat contacted with
the Breakwater.
On the GPS plotter on this boat, the East Breakwater was shown. It is desirable to utilize
the GPS plotter effectively, because the plotter can give information effective to avoid an
accident, when navigating in the nighttime in the area where the light from the target lighthouse
cannot be visually identified due to confusable lights from a lot of other vessels.
The skipper, being required to make proper decision to cope with a variety of risks and
dangerous situations which would occur while controlling the vessel, should refrain from
drinking because the drinking brings about adverse influence on the decision making in
controlling the vessel and may make the proper maneuvering impossible.

11) Marine accident of fatality of stevedore of cargo ship STAR KVARVEN

(Published on February 24, 2012)
It is somewhat likely that this accident was caused because the signal person used the
maintenance ladder instead of the regular pathway for moving around the ship for loading and
unloading of the cargo.
It is desirable that the Shinmaru Koun Co., Ltd. should make their foremen check the safety
of the pathway on which workers move around during loading and unloading the cargo, and make
their foremen let the safe pathway well known to the workers.

12) Marine accident of contact (with sediment control groin ) of motor boat SAN
(Published on March 30, 2012)
It is probable that this accident occurred as the result of the following series of events. On
this boat running back to her marina in Kanazawa Port in the nighttime, the skipper was alone
to control the boat and could not confirm the light from the light buoy due to improper lookout; he
kept running the boat without noticing the boat was approaching the sediment control groin; and
finally the boat contacted with the groin.
The skipper, even if navigating in the familiar area, is required to make an effort to
navigate safely by carrying out the lookout conscientiously and by confirming the ship's position
with a GPS plotter or others.

13) Marine accident of fatality to a crew member and fishing passenger of recreational fishing
vessel KAIRIN MARU
(Published on March 30, 2012)
1. Cautions in handling ship's anchor rope
It is probable that this accident occurred as the result of the following series of events. The
master of the recreational fishing vessel KAIRIN MARU was adjusting the anchoring position in

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the fishing spot off the west-southwest of Hinomisaki; he was trying to unhook the anchor rope
caught on the stern bottom of the vessel and tightened; he was caught on his right ankle with the
anchor rope on the quarterdeck and pulled by the rope that was drifted away out of the deck
under the pressure of wind blowing leeward of the vessel making him fallen in the sea; and a
fishing passenger trying to prevent the master from falling also fell in the sea.
In view of this series of event leading to the accident, it is most likely necessary for every
crew member to be very careful when he is handing such ropes as anchoring rope so that he won't
be on the rope, step over the rope or put the leg in the loop of the rope in order to prevent the leg
from getting caught by the rope.
2. Measures to ensure the safety of fishing passengers and the like
It is probable that the fishing passenger if he put on a lifejacket would have been saved after
he fell in the water; however that he did not have time to put on it because he rushed out of the
cabin trying to save the master.
On the other hand, it is somewhat likely that two of other fishing passengers did not know
where the life ring buoys were stored; that only if they were well informed of the storage space,
then they would have thrown the life ring buoys soon after the fishing passenger fell in the water;
and that the fishing passenger fallen in the water would have been saved.
It is also probable that the master did not instruct the fishing passengers to put on the
lifejacket or did not put it on by himself when he was engaging in anchor work in spite of the
operational rules, in which it was stipulated that the master should try to ask the passengers to
put on the lifejacket while they were onboard and that the master should put on the lifejacket
when there was any risk of falling into the sea.
In view of the above presumption, it is desirable to observe the followings in order to ensure
the safety of the fishing passengers on the recreational fishing vessel:
(1) The recreational fishing vessel operators are to clearly stipulate in their operational rule that
they let the passengers know where the life ring buoys are stored, and that to make sure to
inform them of the storage space before departing the port. This is because of that the fishing
vessel is operated with a few crew members; that the passengers are on the deck most of the
time; and that the passenger(s) will have to take the lead in the rescue activities if, like this
case of the accident, the master falls in the water or if someone falls in the water out of eyesight
of crew members.
(2) The recreational fishing vessel operators are to, in accordance with their operational rule, try
to make the fishing passengers put on lifejacket; as a matter of course the master shall put the
lifejacket on whenever he or she is doing any works that have possible risk of falling into the
sea; and in order to permeate the habit of wearing the lifejacket among the fishing passengers
the crew members are to take the initiative and set a good example for the fishing passengers
by putting on the lifejacket.
(3) The Fisheries Agency and every administrative divisions are to provide the operators of
recreational fishing vessel with advices and/or guidance necessary for them to put the above (1)
and (2) in action.

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14) Marine accident related to swimmer injury by personal water craft (unnamed)
(Published on March 30, 2012)
It is probable that this accident occurred as follows: In the course of driving a personal
water craft (PWC), the driver, without license for personal water crafts, decided to head the PWC
along the sandy beach for the sunshade tent on the Kusuhama coast, and steered it accordingly
while slowing down its speed. He thereupon lost his balance and narrowly escaped from falling
into the sea. He struggled to hold himself stable but failed and was thrown out into the water.
The PWC left his control and ran on to collide with two swimmers who were heading from the sea
toward the sands.
For any PWC driver, it would be essential to previously obtain a driver's license for personal
water crafts, to be fully careful of avoiding the act of approaching to or running around
swimmers, and also the act of dangerous PWC operations such as high-speed running, sudden
turning, and meandering, and to train himself for acquiring better knowledge and skills to ensure
safe PWC maneuvering free of collision with swimmers, always with awareness that a PWC
collision with a swimmer can give serious damage to the swimmer even when the PWC is running
at a low speed.
It also seems likely to be important that a PWC driver, when driving it, should have a kill
switch cord tied to his wrist or other body part in preparation for unexpected emergency
including his own accidental fall into the sea.
While necessary information for the licensing and safe operation of PWC is published in the
homepages of the Ministry of Land, Infrastructure, Transport and Tourism, the Japan Coast
Guard, and marine organizations and institutions, or by their other means, more penetrating
information is desirable in future.

15) Marine accident related to death of stevedores of cargo ship SINGAPORE GRACE
(Published on April 27, 2012)
This accident is likely to have occurred in the No.3 hold of this cargo ship moored to the
private wharf of Saganoseki Smelter and Refinery of Nikko Smelting & Refining Co., Ltd. for
discharging cargo work of copper sulfide concentrate when a stevedore entered the hold in which
oxygen was deficient, and was stricken with anoxia, and subsequently when other workers
entered the same hold to rescue the collapsed stevedore and suffered also from the same disease.
1 To personnel who are engaged in the transport and the cargo operation of copper concentrate
The Japan Transport Safety Board requests to the personnel who are engaged in the
transport and the cargo operation of copper concentrate to pay further attention to the followings:
(1) In order to know the atmosphere of enclosed space, it is necessary that the O2
concentration and gases to be measured properly.
(2) It is necessary that personnel should understand the atmosphere of enclosed space. No
personnel should enter into enclosed space until the atmosphere becomes safe by forced
draft, etc.
(3) It is necessary that personnel should keep in mind that it is not easy to enter the cargo
hold and rescue quickly the injured, and that once anoxia developed, it is difficult to return
from the cargo hold alive.
2 To the industry involved in the transport and the cargo operation of copper concentrate
Due to the risks in dealing with copper concentrates, the Japan Transport Safety Board

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urges the Japan Mining Industry Association, the Japanese Ship Owners’ Association, All Japan
Seamen’s Union, Japan Port Transport Industry Safety & Health Association, Japan Federation
Dockworkers Unions and Japanese Confederation of Port and Transport Workers Unions to make
this report known to those whom it may concern.

16) Marine accident related to passenger ferry ORANGE GRACE collision (against quay)
(Published on April 27, 2012)
This accident seems to have occurred as the advance inertia control by the starboard main
engine of this ferry was lost owing to the total rupture of the elastic body for the starboard elastic
shaft coupling when this ferry was maneuvering to come alongside the pier in the No.1 Section of
Matsuyama Port.
The deterioration of rubber, of which the elastic body was made, develops on account of
fluctuating torque caused by the main engine and also develops under environmental factors
including heat, oxygen and ozone, to eventually entail cracks, creep, and hardening which, if left
uncared, can lead to the rupture of the elastic body.
For the ship owner and the chief engineer who are responsible for the maintenance
management of the elastic body, it should assumedly be necessary to understand that rubber
deterioration in aging is unavoidable and therefore to conduct the maintenance implementation
of the elastic body, planned with not only operating times but also the length of times of use taken
into account.

17) Marine accident related to collision of passenger ferry FERRY KITAKYUSHU with the
chemical tanker KOKI MARU No.78
(Published on May 25, 2012)
It is probable that this accident occurred as follows: When the passenger ferry FERRY
KITAKYUSHU (FK) passed by the No.4 Buoy and took its course along the Kurushima Strait
route, the master determined that the FK could overtake the chemical tanker KOKI MARU
No.78 (KM78) to safely run into the West Channel, and started to pass the KM78. When being
ahead of the KM78, the FK had already been at the point of course change to the West Channel,
and then directed its course rightward to the West Channel, which obliged the FK to cross the
forward traffic course of the KM78, to come into collision with it.
A consideration here is that the FK master was aware his ferry was 3 minutes behind the
scheduled time for the entry in the Kurushima Strait route. Along with the "No-Overtaking"
zone that had been newly established, Meimon Taiyo Ferry Co., Ltd. had revised its ferry
operation timetable, reflecting the reduced ferry traffic speed through the Kurushima Strait
route. This reduced traffic speed in the timetable reduced the significance of the delay of the
FK. There had been no instructions given to relevant ships for preparations for possible delays
in traffics at reduced speed through the Kurushima Strait route. It is therefore probable that
the FK master reckoned that the FK would delay by about 20 minutes if it should navigate the
Kurushima Strait route at the rear of the fleet and decided to overtake it.
It is therefore desirable for all ships navigating through the Kurushima Strait route and for
all of their owners to prevent the recurrence of this kind of accidents with efforts as follows.
(1) If a ship heading through the West Channel toward its northern outlet should find ahead a
fleet of ships navigating in the same direction, the ship should not easily attempt overtaking

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them but should stick to safe navigation, considering the difficulty of navigation through the
Channel route and reckoning of the location of the course change to the West Channel.
(2) A ship navigating through the Kurushima Strait route should maintain sufficient distances
between ships traveling before and behind it in the same Channel, considering its own speed
and tidal currents in the Channel.
(3) When a ship is going to change its course at a curved area, previously make a final backward
check on the side toward which it is going to change, and then change the course while
maintaining safe distances between ships traveling before and behind it.
(4) A ship-owner should provide thoroughgoing directions and instructions for the possible delay
of its ships when navigating through the Kurushima Strait route, with emphasis placed on
no-overtaking.

18) Marine accident related to collision between cargo ship DAISENZAN MARU and recreational
fishing vessel HISA MARU
(Published on May 25, 2012)
It is probable that this accident occurred as follows: On waters off the northwest of Oshima,
under hazy weather, the cargo ship DAISENZAN MARU (DM) was heading southwest, while the
recreational fishing vessel HISA MARU (HM) was drifting about there. Both the master of DM
and the skipper of HM used no radar but relied on visual lookout, assuming that there would be
no other ships around there, to incur the collision.
Seeing that steerers are constantly required to measure the possibility of collision with
other vessels, lookout not only by eyesight but by using furnished equipment such as radar as
well is considered essential.
The skipper of a recreational fishing vessel, in particular, may be needed to do work other
than the vessel steering, so as to meet fishing passengers' requests. In a case like this, it is
considered necessary to accurately grasp the surrounding situation, to immediately stop doing
such other work, and to ensure the safety of the fishing passengers.

19) Marine accident related to collision of recreational fishing vessel KAMOME MARU against
breakwater
(Published on May 25, 2012)
It is probable that this accident occurred when this vessel collided against the breakwater in
the Nakaminato Port, because the vessel skipper had started recording the location of floating
items, without carefully watching around as the vessel had been navigating off the east of the
Port toward the Port, under densely fogged view-obscured weather, and did not notice that the
vessel was approaching the breakwater.
Seeing that a recreational fishing vessel skipper is required to ensure the safety of their
fishing passengers, it will be necessary for the skipper to be always accurately conscious of
surrounding circumstances even when working for other than vessel steering.

20) Marine accident of grounding of traffic boat FRESH ARIKAWA

(Published on June 29, 2012)
It is probable that this accident occurred when the skipper of this boat, who, seated in the

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cockpit, had been manually steering alone the boat westward, off the north of the Kanagashirase
situated to the north-northwest of Enoshima, fell asleep and allowed the steering wheel to be
turned counterclockwise and, consequently, the boat, while curving leftward, moved toward and
grounded on the rock.
It is considered necessary for the skipper, when steering a boat, to be always careful for
preventing himself from falling asleep, particularly when monotonous steering continues or when
drowsiness is likely to become overwhelming typically in circadian or semi-circadian rhythms,
and, if should feel drowsiness is approaching, to try to take resisting actions including a change to
standing steering. It is also considered necessary for the boat owner to be careful of the air
condition in the steering chamber to reduce the possibility of the skipper's dozing and to take
prompt action in the event of an air-conditioner failure.
If a bridge navigational watch alarm system were equipped, the warning buzzer might have
awaken the dozing skipper to serve to avoid this accident. It is desired, therefore, that the boat
owner equip his boat with such a system.

21) Marine accident related to injuries of passengers on motor boat SUZU

(Published on June 29, 2012)
It is probable that this accident occurred as follows: When this pleasure boat was heading
south on waters between the eastern piers of the bridge and Tosaki at the Naruto Strait, where
waves were rising on the south current flowing at a velocity of about 8 kn under the south wind of
about 2.9 m/s, the skipper chose the course onto the rising waves, and the boat was upheaved and
brought down, causing five of the passengers on the flying bridge to pop up off and down to their
seats or the floor with bumping impacts to injure them.
It is desirable that small vessels including motorboats should avoid navigating the Naruto
Strait, if not well informed of the tidal current and wave characteristics there, and that small
vessels navigating there should, prior to departure, make sure of the times of changes and the
directions of the current, and the time and velocity of the current at its highest, as well as wind
directions and velocities there by referring to Sailing Directions for Seto Naikai and Internet
information provided by the 5th Regional Coast Guard Headquarters, and should have
meteorological and sea condition data in addition to the data of the topography and shoals there
previously examined by Chart W112 (Naruto Kaikyo). When wind blows in the direction
opposite to that of the tidal current in the Naruto Strait, navigation there should preferably be
held back.
Passengers on a small vessel who are on its exposed deck such as a flying bridge should
preferably wear a life jacket if there can be a danger of fall from the deck.

22) Marine accident related to collision between cargo ship SHINKENWA MARU and cargo ship
SHOWA MARU No.8
(Published on June 29, 2012)
It is probable that this accident occurred when the cargo ship SHINKENWA MARU (SKM)
was navigating south south-east off the north of Naruto Kaikyo and the cargo ship SHOWA
MARU No.8 (SM8) was navigating north-northwest under foggy visibility-restricted weather, the
master of SKM not watching out by radar, while the master of SM8 maintaining its course and
speed unchanged, to come to collision with each other.

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The Naruto Kaikyo in which this accident occurred is a strait where the navigable passage
is narrow, tidal current is rapid, and fishing boats are operating sometimes, all these possibly
being factors to restrict collision-avoiding actions, and it is considered therefore that the master
of a cargo ship passing this strait under visibility-restricted conditions is required to pay careful
attention to the early detection of other ships in the strait by appropriately using radar ranges
and, on finding any other ship, to practice systematic observations, including radar plotting, of
such other ship and to make sure of its navigation situations using VHF, so as to promptly
determine the probability of the danger of a near miss or collision with the other ship in
accordance with the requirements of Section 4, Article 19 of the Act on Preventing Collision at
Sea, so that the master should take actions to avoid such danger if the probability is high.

23) Marine accident related to grounding of cargo ship DAIKO MARU (Published on June 29,
2012)
It is probable that this accident occurred as follows. When this ship was heading northwest
off the east of Kuji Port at night, the second officer on duty alone on the bridge fell asleep, and his
foot happened to hit the course control dial to turn the dial counterclockwise, which caused the
ship to turn in the direction of the coast to the northeast of Kuji Port and to run aground a reef at
the coast.
Since the time zone from midnight till early morning is a period for a bridge officer on duty
to become liable to doze, it is considered probably necessary that the officer should take positive
care for holding off sleepiness by, for instance, doing the duties in a standing pose, and that, if the
ship is equipped with a bridge navigational watch alarm system, the system should be kept
operative and a timer should be previously set appropriately.

24) Marine accident related to collision between fishing vessel DAIKO MARU and fishing vessel
MIYAJIMA MARU
(Published on June 29, 2012)
It is probable that this accident occurred when the fishing vessel DAIKO MARU, which was
running southeastward, and the fishing vessel MIYAJIMA MARU, which was drifting about,
both at sea to the southeast of Sensui Island, collided with each other because both of the
skippers of the vessels failed to keep watch appropriately.
Every fisherman operating or navigating on the sea, even when on familiar marine zones,
will be required to bear in mind that navigation courses will always be varied and that the
practice of careful navigation and constant appropriate lookout is always important to avoid
collision.

25) Marine accident related to collision between motor boat YOSHIOKA MARU and racing boat
(unnamed)
(Published on July 27, 2012)
It is probable that this accident occurred when the motorboat YOSHIOKA MARU, which
was running eastward, and the racing boat, which was running westward, inside Katakami Port,
collided with each other because both of the skipper of the motorboat and the rowers of the racing
boat failed to keep watch appropriately.

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A skipper when driving a motorboat is required to keep its windshield clear and to keep
lookout appropriately so that no blind sector will intervene in his view of the bow, by changing his
position, e.g. by standing up.
The rowers of a racing boat, when exercising alone, are required to pay careful attention to
other boats or ships by alternately and evenly turning their heads forward.
For the prevention of collision with other ships, the rowers of a racing boat are also required
to be versed in the basic marine traffic rules provided by the Act on Preventing Collision at Sea
and the Act on Port Regulations as well as to abide by the water area safety rules for their rowing
area.
In addition, it is desirable that the rowers wear life jackets for emergency, have simple air
horns or so, capable of sounding signals to tell their presence to neighboring ships, and have
portable waterproof phones or similar tools for communication.

26) Marine accident related to injury of crewman of cargo ship TSURUYOSHI MARU No.3
(Published on July 27, 2012)
It is probable that this accident occurred as follows: When this cargo ship was weighing her
anchor at night off the Ichikawa Fairway of Chiba Port under such circumstances as storm,
high-sea and drag anchor warnings had been issued for that district, the 1st officer was engaged
alone in the anchor weighing work on the forecastle deck and was overturned by a surge of
overriding waves as he had not noticed the surge, and was injured.
It seems likely that the master of this ship, without obtaining latest weather and sea
condition information, cast anchor off the Ichikawa Fairway where laver farms were located, and
that, had the master immediately informed the injury of the officer to the Japan Coast Guard,
prompt makeshift treatment advices could have been given from medical facilities, to alleviate
the injury.
Desirably, the operator of a ship should give directions to the master of a ship under the
operator's ownership or management, to make it a practice to:
(1) obtain latest weather and sea-condition information prior to casting anchor;
(2) for the purpose of preventing net entangling and stranding by anchor dragging, choose an
anchoring location free from obstructions and shoals in consideration of obtained information
per (1) above as well as of wind direction in which wind velocity will be highest, and also choose
an anchoring method with the extension capacity of the anchor cable in rough weather taken
into account; and
(3) in the event of an injury accident, immediately contact the Japan Coast Guard and the
operation manager to obtain first-aid treatment instructions.

27) Marine accident related to collision between cargo ship SEIREI MARU and cargo ship
GYOREN 1
(Published on July 27, 2012)
It is probable that this accident occurred when the cargo ship SEIREI MARU (SEIREI) was
heading southwest and the cargo ship GYOREN 1 (GYOREN) was heading northeast off the east
of Aijima Island under a foggy visibility-restricted situation, and they collided with each other,
because the officer of SEIREI kept on moving without changing her course and speed assuming

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that GYOREN would change her course to avoid possible contact, and also because the boatswain
of GYOREN was not duly watchful of the radar.
It is also probable that the officer of the watch were not complying with the provisions of
the Operation Manual and that the operators of both of the two ships had not provided the ships
with fog information in spite of the foggy season.
(1) Ship operators should obtain fog information from homepages or so of the Japan
Meteorological Agency and provide ships under their ownership or management with such
information.
(2) Ship operators should give the following directions to their ship crew:
i) Whenever the visibility has come to a level specified in Section 4, Article 3 of the Operation
Manual, the officer of the watch must report it to the master without hesitation and the
master must take appropriate actions, including a watch duty support, according to the
provisions of the Manual.
ii) The navigation law applicable to visibility-restricted situations must be observed.

28) Marine accident related to injury of passengers on passenger ship RYOMA

(Published on August 31, 2012)
It is probable that this accident occurred relative to the fact that, although the master and
crewmen of this ship of Tokyo Cruise Ship Co., Ltd. used to call passengers' attention, by
broadcasting and passenger cabin safety check, to the danger of possible catch of passenger's
hand or fingers in the passenger cabin windows on the second floor of this ship when the
passengers should open or close the windows, this cruise ship Company had no recognition of
such danger and had not provided procedures to safely open and close the windows as well as to
previously check the safety.
In view of this fact and based on the investigation results of this accident, the Japan
Transport Safety Board, with the intention of better contributing to the recurrence prevention of
this kind of accidents, hereby expresses its comments as follows and requests the Japan
Passengerboat Association to make this report known to, and to call greater attention of, all of the
Association's concerned parties.
It is advisable that the owners of passenger boats that have windows in their passenger
cabins whose opening/closing operations are remote-controlled should provide safety means to
ensure the safety of passengers and crew, as follows.
(1) The windows should as far as possible have a construction that cannot hold the hands and
fingers of passengers.
(2) For window construction that can hold hands or fingers, appropriate protective means should
be provided.
(3) For windows that may hold hands or fingers when such windows are operated, a window
operation safety checking procedure and window operation-related procedures should be
previously established and crewmen should be trained by the procedures. For passengers
having access to such windows, accident preventive means should also be provided, such as
warning notices posted near such windows.

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29) Marine accident related to collision of liquefied gas bulk carrier RYOAN MARU against Light
Beacon
(Published on August 31, 2012)
It is probable that this accident occurred when the master of this carrier, heading north
along the Nakanose Traffic Route at night, directed her bow toward the No.1 light beacon as the
carrier was overtaking another ship in the same Route, and kept on moving her toward the
beacon until she collided with it, because the master had directed the able seaman to turn the
bow rightward after overtaking the another ship, with the intention of avoiding the beacon
following the overtaking but because this direction failed to be observed owing to the lack of
communication, that is, the communication was not sufficiently shared with, within the bridge.
It is considered probably necessary that able seamen on duty on the bridge should share
information with to have good understanding among themselves by utilizing available means
including BRM, and that a master and officers of the watch should make it a practice to give
steering commands clearly, to have given steering commands repeated by the steersman, and to
have steering condition information reported to them.
It is desired that ship owners continuously implement effective BRM training in order to
build up a system to ensure smooth communication and information sharing among bridge
officers and seamen so that errors among them can be corrected by their interactions.

30) Marine accident related to injuries of workers on pure car carrier VEGA LEADER
(Published on August 31, 2012)
It is somewhat likely that the accident occurred because, while the ship was loading cars at
Nissan Motor Honmoku Wharf, Yokohama Section 5, Keihin Port, the Deck Panel on the car deck
No. 7, not supported by Deck Support 2, while the car loading on the Deck Panel progressed,
fell-down onto car deck No. 6, and the ten longshoremen working on the Deck Panel or on car
deck No. 6 immediately below the Deck Panel were injured.
It is somewhat likely that, while the ship was proceeding to Kanda Port, the Deck Panel,
when readjusted from the middle position to the normal position, was lowered without anyone
being aware that Deck Support 2 was neither fully open nor in a state to support the Deck Panel,
and Deck Support 2 moved outward from the Deck Panel.
Port-transportation-service providers are recommended to regard deck supports on a
liftable deck as dangerous parts and confirm that the deck panel, on which cars will be loaded,
should be correctly supported by them before loading.

31) Marine accident related to collision between cargo ship MEDEA and fishing vessel KOSEI
MARU
(Published on September 28, 2012)
It is probable that this accident occurred as follows: When the cargo ship MEDEA was
moving southwestward under the guidance of a pilot, while the fishing vessel KOSEI MARU
(KM) was moving westward, off the southwest of the East Route of Nagoya Port at night, the pilot
directed to change her course leftward to lead her to pass by the east side of the No.6 light buoy,
which brought her to approach KM, while the skipper of KM, unaware of the approaching
MEDEA, continued to move on toward a forward part of the MEDEA's course, to result in

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collision with each other.

There seems to be a possibility that the absence of appropriate lookout by both the master
and the skipper and the lack of information sharing among the pilot, master and third officer of
MEDEA about the movement of other boats including KM took part in this accident.
(1) It is desirable that WALLENIUS MARINE SINGAPORE PTE LTD. give the following
directions to the masters of the ships under its ownership or management:
i) Every master, on his boarding a ship, should make sure of the location of her whistle so
that he can immediately blow it in an emergency.
ii) Every master should positively utilize BRM techniques so that he can share other vessels'
information with her pilot whenever she is under the guidance of the pilot.
(2) It is desirable that the Fisheries Cooperative Association to which KM belongs makes the
followings thoroughly known to all of its member fishing vessels:
i) Every skipper, whenever preparing on a ship-crowded sea area, for fishing, should practice
careful lookout using timely means including a radar so as to be able to find approaching
vessels if any.
ii) It should be borne in mind that a visual lookout immediately after a work in a brightly
illuminated place at night can hardly find other vessels because the vision may not be
dark-adapted, and that working lights on the front of a steering house will be obstructive to
lookout.
(3) It is desirable that the pilots’ associations, of which the pilot of this accident was a member,
considers giving BRM education and training to all its member pilots in order to effectively
implement BRM techniques to ensure that every pilot on duty will keep the master informed of
the steering condition of their ship and will be promptly and positively informed from the
master of the movement of other approaching vessels, if any, thus, will share information
among them so that they can perform safe navigation, and is also desirable that the society
endeavor anew to improve their skills relative to the IMO standard marine communication
terms.
(4) We request anew the Japan Federation of Pilots’ Associations to make effort to improve the
skills of its pilots relative to the IMO standard marine communication terms through its safety
training programs implemented every 5 years.

32) Marine accident related to diver injuries of diving boat YDS VII
(Published on November 30, 2012)
It is probable that this accident occurred as follows: When this boat was drawing up a diver
at its stern offshore the northwest of Umabana-saki, a diving instructor dived into beneath the
stern bottom because the boat had a fast backward momentum, advanced while rolling along the
bottom toward the bow, and accidently contacted the propeller blade. At the same time, the
passenger diver accidently got both of his flippers caught between the lowered ladder and the
outside plating of the stern, fell into the water headfirst and contacted the boat bottom.
For preventing the recurrence of this kind of accident, therefore, it is considered necessary
for the diving-related marine pleasure providers to implement the preventive measures as
follows.
Considering that the Okinawa Prefectural Public Safety Commission has been energetic in
giving instructions for ensuring the safety of diving passengers, the Japan Transport Safety

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Board requests the Commission to cooperate for giving directions to diving-related marine
pleasure providers for the implementation of the safety measures as follows.
(1) Giving cautions and instructions and making them well known when drawing up divers from
waters to a diving boat
Diving-related marine pleasure providers should make the following cautions well known
to their boat skippers and should instruct the skippers to observe them:
i) The diving boat skipper, when approaching a diving passenger, should approach at an
immediately stoppable speed and should stop the boat before the diver comes in the blind
spot of the boat.
ii) If a diving boat is equipped with a means of communication with a sea-surface instructor
or a diving passenger, such as an underwater speaker, the skipper should use such means
and announce the boat approaching situation to the diving passenger.
iii) As far as practicable, the skipper should assign a watcher or an instructor to watch out
abroad for diving passengers' access to the boat.
iv) The instructor should carry a communicating means such as a whistle and inform the
skipper by using it in the event of the danger of a possible nearing of the boat.
v) When taking actions to stop the boat and to bring up a diving passengers from waters, the
skipper should make sure of the standstill of the propeller and then advise the diving
passenger-guiding instructor that the boat is ready for bringing up the passenger.
vi) Upon receiving the information per v) above, the instructor should confirm that the
propeller is in stoppage and then guide the passenger up onto the boat.
(2) Posting cautions for diving boats
Diving-related marine pleasure providers should post the cautions per (1) above at
noticeable places from a skipper and should provide means for communicating with the
instructors, to ensure the implementation of the cautions
(3) Report of underwater current information from instructor to skipper at start of diving
With a view to assuring that a diving boat can stand by at an apposite water area upward,
the instructor should check the underwater tidal current and inform it to the skipper.
(4) Consideration of diving boat and instructor equipment
i) Diving-related marine pleasure providers should consider installing a propeller guard in
their diving boats for the purpose of preventing accidents at the time of drawing up diving
passengers from waters.
ii) Diving-related marine pleasure providers should consider prearranging the instructors to
carry a radar wave reactive float or so which can facilitate detecting diving passengers on
sea surface.

33) Marine accident related to collision of oil tanker PACIFIC POLARIS against berth
(Published on December 21, 2012)
It is probable that this accident occurred as follows: When the oil tanker PACIFIC
POLARIS was in the process of her port being moored alongside the No.1 Berth in
Kin-Nakagusuku Port, her stern approached the No.1 Berth at a landing speed of 15 to 18 cm/s,
with her stem away at about 7 to 8º from the Berth, because the berth master who was engaged
in a quasi-pilot work had no idea of the approaching condition of the PACIFIC POLARIS stern
toward the Berth, and the port stern collided against the H-steel beam of the dolphin of the

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Berth.
Practicing the following, therefore, may be useful for the prevention of the recurrence of
similar accidents:
1) The berth master will dutifully make sure of the operating condition of the engine and tag
boat and of the approaching condition of the ship close to a pier, and to abide by the
requirements for laying the ship alongside the pier.
2) The master will reasonably watch the steering operation by the berth master and will
question the berth master if find the berth master's operation questionable.
For the purpose of preventing approaching ships for mooring from being damaged, it is
desirable that the owner of the Berth will either modify the Berth to have no steel structural
projection or attach suitable fender to the projection.

11. Actions taken in response to recommendations in 2012

Actions taken in response to recommendations were reported with regard to three marine
accidents in 2012. Summaries of these reports are as follows.

1) Marine accident related to injury of passengers of passenger ship AN-EI GO No.98

(Recommended on March 25, 2011)

Concerning the passenger injury accident of Passenger Ship AN-EI GO No.98 occurred off
the northeast of Iriomote Island at Taketomi-cho, Okinawa Prefecture, on April 30, 2009, the
Japan Transport Safety Board published a report on the investigation results of the accident and
concurrently gave recommendations to Anei Kanko Co., Ltd. who was responsible for the cause
of the accident, on March 25, 2011, and received a report on April 23, 2012 on the completion of
the implementation of recommendation-based measures as follows.

● Outline of the Accident

At about 09:40 hrs, Thursday, April 30, 2009, while the ship, boarded by a master with
an ordinary seaman and 28 passengers, was underway from Iriomote Shima (Iriomote Island),
Taketomi Town, to Ishigaki Shima (Ishigaki Island), Ishigaki City, Okinawa Prefecture, two
passengers suffered injuries when the ship pitched (moved up and down).

● Description of Recommendations
1. Safety education on the safety management manual
The company should regularly provide its crew with proper safety education on the
company’s operation standards, putting emphasis on measures for safe operation while
underway on rough seas, and ensure their compliance with the standards.
2. Development of and compliance with safety manual for navigation on rough seas taking into
account actual operation
In order to ensure implementation of its safety management manual, the company
should review its safety measures on rough seas in terms of route, speed, use of seatbelt,
instruction for passengers to move to a place with less ship motion, and so forth, taking into
account the size and the cabin arrangement of the ship in service, to develop a safety manual

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for navigation on rough seas, provide education its crew about the manual, and ensure their
compliance with it.
● Outline of Completion Report
1 Safety education relating to safety management regulations
・ We implemented safety education for safe navigation (including safety education in other
fields).
・ Conducted information obtainment by means of questionnaire at short courses of lectures,
for the purpose of sounding out the crewmen's understanding of the Safety Management
Regulations. For crewmen whose understanding of the Regulations was found
insufficient, we conducted course education again.
2 Preparation and observance of instruction manual for safe navigation on heavy sea, suited
for actual situations for specific navigating passenger ships
・ We prepared “Instruction manual for safe navigation on heavy sea” which contains "Safety
measures for passengers on heavy sea" and "Cautions for safe navigation on heavy sea"
described in the navigation criteria charts for the specific navigation courses, in the form
of attachment to the existing safety measures, and we gave education to the crewmen
accordingly.
・ We made a survey about what the crewmen take care when weather is stormy at sea and
informed the survey results to all of the crewmen.

2) Marine accident related to capsizing of cutter (unnamed)

(Recommended on January 27, 2012)

Concerning the investigation of the capsizing accident of the cutter (unnamed) occurred on
June 18, 2010 in the north of Lake Hamana in Hamamatsu City, Shizuoka Prefecture, the Japan
Transport Safety Board published its accident investigation report, placed recommendations
with the accident-responsible party Shogakukan-Shueisha Productions Co. Ltd. and with the
Shizuoka Prefectural Board of Education on January 27, 2012, and received reports from them
on the measures taken (or planned measures) based on the recommendations on July 11, 2012 as
follows.

● Outline of Accident
The cutter (unnamed), with 18 students and 2 teachers aboard it for rowing training as
part of the outdoor class activities of the junior high school at Mikkabi Youth Center, was
engaged in rowing for the training but, as the wind and waves became so high as disenabling
the rowing, came to be tugged by a motor boat MikkabiYouthCenter of the Center. At around
15:25, June 18 (Friday) 2010, when moving southwestward off the south of Sakume at Lake
Hamana, the cutter capsized portside.
One of students confined within the capsized cutter died. One of oars was broken, but
the cutter body remained intact.

● Description of Recommendations
1. Shogakukan-Shueisha Productions Co. Ltd.
1) The criteria for cutter training suspension and the cutter training methods used at the
Youth Center should be reviewed to ensure their adaptability based on the experience of

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the trainees, and the following provisions should be included in the instruction manual:
a. The criteria for suspending training when weather advisories are broadcast.
b. The criteria for suspending training under bad weather other than when weather
warnings or advisories are broadcast.
c. Training methods under bad weather.
d. The time for deciding the permission or no of training and the time (including a time
during training) for deciding a training method.
e. Treatment of training if suspended on its way.
f. Provisions for safety in training (including the arrangement and duty of a guard boat,
constant contact with weather information, and preparations for the tow of cutter).
2) A rescue system, supposing cutter accidents and including procedures for tugging and
rescuing a cutter, should be established, and the Youth Center personnel should be
periodically trained. Effort should be made to strengthen cooperation with rescuing
agencies.
3) Effort should also be made to improve the knowledge of the Youth Center personnel with
respect to cutter and weather, and to inspire their consciousness of securing training
safety.
2. Shizuoka Prefectural Board of Education
The Board should review the criteria for training suspension, the training methods,
and the emergency management manual of the Youth Center, should give them necessary
corrections, if found any, and should have tow training practiced.

● Outline of Implementation Plans

1. Shogakukan-Shueisha Productions Co. Ltd.
1) Implementation plan based on recommendations 1)
[Arrangement Policy]
(1) We will establish criteria for determining permissible safe and sound activities free of
accidents in the course of "marine activity programs" at Mikkabi Youth Center.
(2) We will establish criteria for determining training suspension, not based on only the
experience and preconceptions of the personnel at the Youth Center but using actual
specific weather and other information and data, by which determinations by all
concerned parties would lead to an identical or similar conclusion.
(3) We will prepare and maintain a manual according to which prompt and appropriate
actions can be taken in an emergency.
[Specific Safety Measures]
(1) We will identify specific criteria for determining implementation or implementation
suspension.
(2) We will prepare training plans for sudden weather change.
(3) We will define time limits for deciding training implementation or suspension and for
deciding training method.
(4) We will specify treatment to be taken in the event of a training suspension during its
implementation.
(5) We will establish safety measures in training.
(6) We will expressly include in our manual actions to be taken when a cutter is towed.
(7) We will specify in our manual requirements for boarding a cutter.

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2) Implementation plan based on recommendations 2)

[Basic Concept]
(1) We will implement rescue and tow trainings under conditions simulated to
conceivable conditions of accidents, and will keep record of noticed problems at the
Center for common information sharing.
(2) We will make effort to develop better cooperation with local concerned parties (police,
fire department, and private organizations) and will have joint trainings with them as
far as practicable.
(3) In addition to joint training, we will make out our own annual training plan and will
realize it without fail.
[Consideration of Specific Measures]
(1) Concerning rescue
Improvement in knowledge of rescuing methods and in skills and knowledge of
towing
(2) Concerning systems for emergencies
Consideration of rescuing methods and countermeasures for supposed emergencies
including capsizing, periodic practice of rescue and tow trainings in emergencies,
establishment of an organizational system and a chain-of-command structure in an
emergency, strengthening of tie-up with external concerned parties for rescuing, and
preparation of passenger list necessary for checking personal safety.
3) Implementation plan based on recommendations 3)
[Basic Concept]
(1) We will prepare a system to set up minimum necessary training time and acquisition
levels and to allow only those Center people who attained the set levels to participate
in our programs.
(2) Our Center people will be not only trained and educated at the Center but will also
be encouraged to positively attend education and training programs offered by outside
organizations, and the information of such activities will be made available within the
Center.
[Consideration of Specific Measures]
(1) For enriching cutter-related knowledge
Invitation of outside consultants, attendance at outside training, training at the
Center, and information exchange with outside facilities
(2) For improving knowledge of weather
Attendance at weather forecaster qualifying lecture courses, selection of staff
members specialized in weather, routine collection of daily weather data, and
collection of areal data from marinas.
(3) For inspiring consciousness of safety in training
Submittal of annual safety management plan, implementation of training for
supposed accidents, collection of actually occurred examples of terrifying but
narrowly escaped incidents, improvement of manual, selection of safety management
specialists, and attendance at safety-related training.

2. Shizuoka Prefectural Board of Education

・To designated managers, the Board will give directions, advices and guidance, with the

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main points of safety requirements provided by Shizuoka Prefectural Board of Education

shown to them, based on comments at manual review meetings to be newly held by the
prefectural safety measure committee and outside knowledgeable people, and will require
the managers to prepare cutter training manual accordingly.
・ For cutter tow training, the Board will require designated managers to establish
implementing procedures, taking into consideration actual towing methods being used at
similar training facilities and based on comments of experts, and to also establish training
procedures in which implementing methods and system capabilities are incorporated,
with comments at manual review meetings taken into account, and to reflect them on
their manuals. The Board will also require them to prepare an annual tow training
implementation plan, to review its appropriateness, and to develop and maintain a system
capable of appropriately carrying out tow training.
・A system will be developed to periodically check to see, and to correct where necessary, if
manuals and tow training implementation methods and plans are appropriately
practicable.

3) Marine accident related to death of stevedores working for cargo ship SINGAPORE GRACE
(Recommended on April 27, 2012)

Concerning the marine accident related to the death of the cargo ship SINGAPORE
GRACE stevedores which occurred on June 13, 2009 at Saganoseki Port, Oita City, Oita
Prefecture, the Japan Transport Safety Board investigated the accident, published on April 27,
2012 its investigation report and concurrently gave recommendations to the concerned
responsible parties, Saganoseki Smelter and Refinery of Pan Pacific Copper Co., Ltd. and Nissho
Koun Co., Ltd., and received a report on September 26, 2012 about the completion of
recommendations-based measures taken as follows.

● Outline of the Accident

At about 08:30 on 13th June 2009 when the cargo ship was berthing at the wharf of
Saganoseki Port for discharging cargo work of copper sulfide concentrate, one of the
stevedores collapsed on his way of going down on the ladder into the No.3 cargo hold for cargo
work, and two of the three stevedores who came to rescue the collapsed also collapsed in the
hold.
The three collapsed stevedores were carried out of the hold but were found dead later.

●Description of Recommendations
1. Saganoseki Smelter and Refinery of Pan Pacific Copper Co., Ltd.
(1) To train all employees who have the possibility of being engaged in cargo work to
understand the properties and risks of copper sulfide concentrate.
(2) To train all employees, who have the possibility of being engaged in cargo work, with the
handling of O2 meters in order to measure O2 concentrations as necessary
(3) To request the MSDS of floatation reagents from shippers.
(4) To inform employees who have the possibility of being engaged in cargo operation on the
following:
[1] Depending upon the properties of the floatation reagent adhered to copper sulfide

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concentrate, it may generate toxic gas.

[2] Since the generated toxic gas is heavier than air, it stagnates in cargo hold; hence,
there is a danger of not being replaced by air.
(5) To make the risks of oxygen-deficient conditions and anoxia known to all personnel who
have the possibility of being engaged in cargo operation and to familiarize them with
appropriate coping behavior in case of fatal accidents occurring in cargo holds loading
copper sulfide concentrate.

2. Nissho Koun Co., Ltd.

(1) To train all employees who have the possibility of being engaged in cargo operation to
understand the properties and risks of copper sulfide concentrate
(2) To train all employees, who have the possibility of being engaged in cargo work, with the
handling of O2 meters in order to measure O2 concentrations as necessary
(3) To make the risks of oxygen-deficient conditions and anoxia known to all employees who
have the possibility of being engaged in cargo operation and to familiarize them with
appropriate coping behavior in case of fatal accidents occurring in cargo holds loading
copper sulfide concentrate

● Outline of Completion Report

1 Saganoseki Smelter and Refinery of Pan Pacific Copper Co., Ltd.
[Implementation Plan Based on Recommendations 1)]
To the concerned people, including our production control section members in the
main, we will conduct education in June (in the preparation period for the nationwide
Safety Week) every year.
The points of the education will be as follows.
1) Copper concentrate is fine powder, has large surface area, and is therefore easily
reactive with oxygen in the air in the cargo hold, to subsequently generate heat by
oxidation. (Copper concentrates consumes oxygen.)
2) As copper concentrate is transported in a carrier from Chile (for about 35 days) ,
Indonesia (for about 14 days) or others, the oxygen concentration within the hold is
often reduced to 18% or below (to a state of oxygen depletion).
3) Oxidative heat generation is often noticeable particularly when much dew is formed
as the hatch is kept open. When such is a case, the oxygen concentration in the hold
could be extremely low and should be taken care of.
[Implementation Results Based on Recommendations 1)]
For the concerned people (16 persons) including our production control section
members in the main, we conducted education on June 18 with emphasis placed on the
three points specified in our Implementation Plan.
We will continue our education in June (in the preparation period for the nationwide
Safety Week) every year.
[Implementation Plan Based on Recommendations 2)]
For the purpose of achieving and maintain a level of the accurate usage of oxygen
concentration meters, we will make our concerned people including the production control
section members in the main join the education class to be opened in June (in the
preparation period for the nationwide Safety Week) among the series of the classes

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planned to be held 6 times a year by Nissho Koun Co., Ltd. for the handling of oxygen
concentration meters.
[Implementation Results Based on Recommendations 2)]
Our concerned people (16 persons) including the production control section members
in the main joined the education class held on June 20 by Nissho Koun Co., Ltd. for the
education of the accurate handling of oxygen concentration meters and learned the
accurate usage of the meters.
We will continue this education in June (in the preparation period for the nationwide
Safety Week) every year to maintain a level assuring accurate usage.
[Implementation Plan Based on Recommendations 3)]
For copper concentrates we shall procure in and after June 2012 through our Raw
Material Procurement Department, we will require the copper concentrate mines to
furnish us with MSDS of the flotation reagents used for them.
Based on furnished MSDS, we will implement the education of the concerned people
including our production control section members in the main in association with the
implementation plan based on the Recommendations 1).
In addition, we will supply obtained MSDS to Nissho Koun Co., Ltd. and will direct
MSDS-related education of all employees of Nissho Koun Co., Ltd. who will be engaged in
cargo handling work.
[Implementation Results Based on Recommendations 3)]
On May 17, through our Raw Material Procurement Department, we requested
copper concentrate mines to supply us MSDS of the flotation reagents. On August 28,
regarding the MSDS of the 4 flotation reagents we could obtain, we carried out education
of the concerned people (16 persons) including our production control section members in
the main.
For other MSDS we may obtain in future, we will carry out similar education
accordingly.
Meanwhile, we supplied our obtained MSDS to Nissho Koun Co., Ltd., which
subsequently conducted education of all its employees who are likely to be engaged in the
cargo handling during the period between 29th and 31st August. We will continue this
MSDS education of obtained flotation reagents. Periodically, in particular, we will carry
out it in June (in the preparation period for the nationwide Safety Week) every year.
[Implementation Plan Based on Recommendations 4)]
In June (in the preparation period for the nationwide Safety Week) every year, in
association with our Implementation Plan based on the Recommendations 1), we will
educate the concerned people including our production control section members in the
main to make them understand that some of the flotation reagents used in the process of
copper ore concentration can produce poisonous gases heavier than air and that such
poisonous heavy gases can pose danger by staying in the cargo hold without being
re-replaced with air.
[Implementation Results Based on Recommendations 4)]
We implemented education along with the implementation based on the
Recommendations 1). In June (in the preparation period for the nationwide Safety Week)
every year, we will conduct the education.
[Implementation Plan Based on Recommendations 5)]

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To the concerned people including our production control section members in the
main, we will give education as follows.
1) Implementation of education about the danger of oxygen-deficient conditions and
anoxia in association with our implementation plan based on the Recommendations 1).
The points of the education will be as follows:
・The mechanism and cause of the onset of anoxia
・Symptoms of anoxia
・Properties and danger of copper concentrate
・Places where anoxia can occur and cautions
2) We will regularly join the training programs planned to be effectuated in March every
year by Nissho Koun Co., Ltd. for the instruction, guidance, and mastering the
treatment and rescuing in the supposed events of personal accidents in a cargo hold
storing copper sulfide concentrates, and will learn appropriate treatment knowledge
and skills.
[Implementation Results Based on Recommendations 5)]
For the concerned people (16 persons) including the production control section
members in the main:
1) We made the danger of oxygen-deficient conditions and anoxia thoroughly known to
them at the education implemented on June 18.
We will continue this education in June (in the preparation period for the
nationwide Safety Week) every year.
2) We arranged and had their participation in the rescue training held by Nissho Koun
Co., Ltd. on June 13.
We will continue to make them join the rescue training programs for the supposed
events of personal accidents in a cargo hold planned to be effectuated in March every
year by Nissho Koun Co., Ltd. and acquire necessary knowledge and skills of
treatment. This year, they joined the rescue training conducted on March 3 by Nissho
Koun Co., Ltd.

2. Nissho Koun Co., Ltd.

1) Concerning the properties and danger of copper sulfide concentrates, we gave education
to 55 workers of the Cargo Handling Section on June 13, 2012 and to 54 workers of the
same on 29th to 31st August 2012 with emphasis on the following points. We will
continue similar education regularly.
[Points of Education]
(1) Copper ore is finely powdery, has therefore a large surface area, and is liable to react
with oxygen in air in cargo holds to subsequently generate heat.
(2) When copper ore is transported from abroad in a cargo hold, the oxygen concentration
in the cargo hold is often reduced to below 18%, i.e., to a state of oxygen insufficiency.
(3) It is known that when the hatch of a hold is kept open and much dew is formed,
oxidative heat generation is active, denoting that the oxygen concentration in the hold
may be extremely low.
(4) A flotation reagent contained in copper ores contains toxic gases heavier than air and
can cause oxygen depletion.
(5) MSDS of flotation reagents contained in copper sulfide concentrates

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2) In regard to the handling of oxygen concentration meters, we gave education to 55

workers of the Cargo Handling Section on June 20, 2012 and to 54 workers of the same on
August 10, 2012 with emphasis on the following points. We will continue similar
education regularly.
[Points of Education]
(1) Types of the meters
(2) Usage
(3) Meter maintenance procedure
(4) Locations to be measured at
(5) Recording procedure
(6) Protectors to be worn
(7) Evacuation in the event of danger
3) In regard to the danger of oxygen-deficient conditions and anoxia, we gave education to 55
workers of the Cargo Handling Section on condition that they should receive the
education once on the three days from 27th till 29th of August 2012, with emphasis
placed on the following points. We will continue similar education regularly.

[Points of Education]
(1) Mechanism and cause of occurrence
(2) Symptoms of anoxia
(3) Properties and danger of copper ore
(4) Places wherein the danger is liable to occur and cautions
4) On June 13, 2012, we conducted emergency training exercises and gave education and
training to 47 workers of the Cargo Handling Section for the treatment of personal
accidents in cargo holds containing copper sulfide concentrates, with emphasis placed on
the following points. We will continue similar education regularly.
[Points of Education]
(1) Criteria for determining whether an oxygen deficiency accident or other accident
(2) Reporting on finding an accident victim
(3) Prevention of secondary accident
(4) Preparations for rescue
(5) Measurement of oxygen concentration
(6) Air supply to victims
(7) Situation comprehension and criteria for determining permissibility for entering the
cargo hold to rescue victims
(8) Cooperation with rescue team

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12. Actions taken in response to safety recommendations in 2012

Actions taken in response to the safety recommendations were reported with regard to one
marine accident in 2012. A summary of it is as follows.

1) Marine accident related to collision between cargo ship MARINE STAR and container ship
TAKASAGO
(Recommended on October 28, 2011)

The Japan Transport Safety Board investigated the collision accident which occurred on
February 20, 2009 in the Bisan Seto East Traffic Route between the cargo ship MARINE STAR
and the container ship TAKASAGO, issued an investigation report publicly and also safety
recommendations to Blue Marine Management Corp. which is the management company of
MARINE STAR on October 28, 2011, and received a responding report on the actions taken in
reply to the safety recommendations on January 25, 2012 as follows.

● Summary of the Accident

The collision occurred at around 06:15 on February 20, 2009 between the cargo ship
MARINE STAR which, with the master and 16 crew members abroad, was sailing northward
off the north of Sakaide Port, and the container ship TAKASAGO which, with the master and
4 crewmen aboard, was moving eastward along the Bisan Seto East Traffic Route.
MARINE STAR suffered depressions in her stern port outer plating and TAKASAGO
also suffered depressions in her bow, but the crew of both of the ships remained intact.

● Description of the Recommendations

The Panama Maritime Authority should guide the ASIA SHIPPING NAVIGATION S.A.
to have the BLUE MARINE MANAGEMENT CORP. execute proper ship management to
secure safe operation.
The ASIA SHIPPING NAVIGATION S.A. should instruct the BLUE MARINE
MANAGEMENT CORP. to follow the navigation rules of the state where vessel call, prepare a
proper watchkeeping arrangement and ensure the safety of navigation.
The BLUE MARINE MANAGEMENT CORP. should provide clear and specific
instructions on the rules that must be obeyed to the ships that navigate in this sea area, and
at the same time guide the ships to ensure safety by reinforcing watchkeeping arrangements
on the bridge through the measures including the increase of the number of crew on bridge
watchkeeping duty.

● Actions Taken in Response to the Safety Recommendations

1) BMMC disseminated “Instruction to Master” to all managed ships regarding this
incident for crew further awareness of the accident stating its root cause and
countermeasures to avoid recurrence.
2) BMMC provide onboard training for bridge personnel to ensure crew are competent to
implement navigational procedures correctly and safety.
3) BMMC launched a year round “Campaign against Collision and Stranding "since the
incident and constantly remind all vessels in the fleet especially passing narrow channels
at Japanese ports, likewise to ensure the crew awareness of safe navigation.

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4) BMMC monitor and ensure that the procedures of the safety management system has
been followed and carrying out evaluation of the safety performance through reporting
systems, by constant visiting of ships by Superintendent to check the safety operation of
the vessel.
BMMC highly appreciate your authority for carrying out investigation with this
accident and ensure to continue and keep monitor its managed ships to further enhance
safety navigation and avoid recurrence of the incident.

 The report (original) from BLUE MARINE MANAGEMENT CORP. is shown on the home
page of the Board.
http://www.mlit.go.jp/jtsb/eng-mar_report/BMMC_20120125_Action.pdf

13. Information dissemination in the process of investigations

The JTSB disseminated information on the following four marine incidents in 2012.
The information is summarized below.

1) Marine accident related to capsizing of fishing vessel KASUGA MARU

(Disseminated on April 5, 2012)

In regard to the capsizing accident of the fishing vessel KASUGA MARU that occurred on
March 23, 2012, the Japan Transport Safety Board supplied information to the Ministry of Land,
Infrastructure, Transport and Tourism and the Fisheries Agency as follows.

(Fact Information)
The facts found to date are as follows.
At the time of this accident, the engine room door on the portside upper deck, the crew
space door at the stern, and the boatswain's store door at the bow of this vessel were open, and
the seawater that came over to the upper deck flowed through the doors into the engine room,
the crew space, and so forth.

2) Marine accident related to the death of personal watercraft LIB passenger

(Disseminated on June 27, 2012)

In regard to the fatality accident of the personal watercraft LIB pillion passenger that
occurred on July 31, 2011 and the injury accident of the personal watercraft FAIRLADY pillion
passenger that occurred on July 23, 2011, the Japan Transport Safety Board supplied
information to the Ministry of Land, Infrastructure, Transport and Tourism as follows.

(Fact Information)
The facts found to date are as follows.
1) Process to death/injury
It is likely that the pillion passenger of the personal watercraft fell into the sea as the
rider was starting or accelerating the watercraft, that sea water entered the body cavities of
the passenger owing to the impacts of the fall and of the jet streams from the waterjet
propulsion system, and that the entered water gave damage to the internal organs to death

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of the passenger.
2) Warnings given in manual
The manual of the personal watercraft LIB contains the written warnings for possible
danger of death or serious harm as stated below.
(1) The rider or passenger is required to wear body protective clothes.
(2) If you should fell into sea and exposed to strong water pressure on account of the impact
of the fall or near the jet nozzle, there is a possibility of water inflow into your body
cavities and subsequent damage to you. Ordinary bathing or swimming suit cannot fully
protect your body. Always wear a wet suit and pants capable of protecting your body.
(3) Whenever somebody is behind the watercraft, do not open the throttle, but stop the
engine or keep it idling. If the throttle should be opened, water and inclusions in it
ejected from the jet nozzle may injure the person.

3) Marine accident related to the explosion of motorboat KEN-YU

(Disseminated on August 29, 2012)

In regard to the explosion accident of the motorboat KEN-YU that occurred on May 2,
2011, the Japan Transport Safety Board supplied information to the Ministry of Land,
Infrastructure, Transport and Tourism and the Nuclear and Industrial Safety Agency of the
Ministry of Economy, Trade and Industry as follows.

(Fact Information)
The facts found by our investigations so far are as follows, although our investigations in
future will disclose more facts.
It is probable that this accident occurred as follows: When the motorboat was moored at
a basin downstream of the river Ohmutagawa, the skipper cleaned the upper part of the main
engine in the engine casing, by using and exhaustively consuming the contents of a cleaning
agent spray can, and then soon closed the engine casing cover and started the main engine.
Thereupon, the mixture of the flammable gases, consisting of gasified cleaning agent and LPG
for jet propulsion and staying in the engine casing, caught electric sparks from the starter
motor and exploded.

4) Marine Accident Related to Collision of Anchor-Dragging Foreign-Flag Ships by Typhoon

(Disseminated on September 6, 2012)

In view of the three collision accidents related to large foreign-flag ship anchor-draggings
that were caused to occur serially in Tokyo Bay during at night of June 19, 2012 till dawn by
violent wind and waves under the influence of the Typhoon No.4, the Yokohama Office of the
Secretariat of the Japan Transport Safety Board supplied the following information to the Kanto
District Transport Bureau, the Chubu District Transport Bureau, the 3rd Regional Coast Guard
Headquarters of the Japan Coast Guard, the Ship's Agency Association of Kanagwa Prefecture,
the Tokyo Bay Licensed PILOTS' Association, and the Yokohama Office of the Japan Foreign
Steamship Association.

(Requisites for Recurrence Prevention)

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 Chapter 4 Marine accident and serious incident investigations

・ Obtain latest weather and sea condition information, and select a place for anchoring
taking into consideration the direction of wind, the depth of water, bottom sediment,
possible height of waves, and lee side distance.
・ Previously calculate the anchor's maximum holding power of the ship and the maximum
tolerable wind velocity, and previously determine countermeasures for possible wind at the
maximum velocity.
・ Keep the draught deeper, and keep the ship from swinging to and fro preferably by holding
a trim by bow. On the other hand, support the holding power of anchor by fully extending
its chain, and select an anchoring method best suited for the situation.
・ Keep the main engine stand-by, ready for anchor relocation.
・ Practice ship location check and lookout such that the drag anchor of own or other ship can
be found early.
・ Constantly listen to VHF to collect information.
・ If the ship is found dragging its anchor, immediately take an anchor shifting or other
appropriate action.
・ If other ship is found dragging anchor, give a call to the ship by VHF with an advice for
shifting the anchor or so.

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Column Motorboat Explosion Accident

This accident arose from the start of the engine of a motorboat to leave a basin in Ohmuta City,
Fukuoka Prefecture, went through an explosion in the engine casing and the blow-off of the casing
cover, and resulted in the injury of two passengers and the fracture of the boat body.

Prior to the explosion, the skipper of the motorboat had cleaned the smeared upper part of the
engines using up a spray can (containing 840 ml) of cleaning agent. The skipper knew that the spray
cleaning agent contained propane gas as an propulsion agent, that propane gas was heavier than air
and was explosive, and that propane gas must not be used where there is fire nearby, but, seeing that
the moment cleaning agent solution was shot upon and wetted the engine's upper part, the liquid
cleaning agent evaporated from there in the form of flammable gas, thought that the propane gas was
also diffusing together with the cleaning agent gas.

It is probable that although both the cleaning agent, when turned to flammable gas, and the
propane gas, were heavier than air, they did not descend to the bottom of the engine casing but were
taken and suspended in the air in the engine casing, caught electric sparks from the cell motor and
exploded.

The spray cleaning agent bore a written warning statement, meaning "Do not use this agent
near fire or flame. Do not use this agent in large volume in a room where fire is used.", according to
the enforcement ordinance notification of the High Pressure Gas Safety Act, but had no statement
giving caution for its use in a narrow closed space where there is a danger of explosion.

For the purpose of drawing more careful attention of small boat operators to the safety indication
of spray-type cleaning agents in view of the recurrence probability of this kind of accidents, the Board
supplied information to the Ministry of Economy, Trade and Industry and the Ministry of Land,
Infrastructure, Transport and Tourism. On receipt of the information, some of the District Transport
Bureaus prepared recurrence preventive leaflets and distributed them to small boat drivers.

At the request of the Board, the spray cleaning agent sales company A took a prompt action of
adding to the said statement a paragraph of caution for use, saying "Do not use this cleaning agent in
a narrow closed space, because flammable gases will stay in such a space." A newspaper publishing
company in Fukuoka Prefecture reported this topic on its newspaper to help make the recurrence
preventive knowledge widely known.

Nevertheless, afterward, a fishing boat incurred a similar accident in Kagoshima Prefecture

again. Considering that all the spray cleaning agent sales companies have not prepared such
cautions for use as Company A provides, and that all the boat operators are not informed of the danger
of explosion of spray-type cleaning agents when used in a narrow closed space, we deem it necessary,
for the recurrence prevention of similar accidents, to make the cautions for use of the spray-type
cleaning agents more thoroughly known.

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14. Summaries of major marine accident investigation reports

A cutter capsized when being towed homeward in bad weather by a motorboat

Capsizing of a Cutter (unnamed)

Summary: On June 18, 2010, 18 students and 2 teachers were in the training of cutter rowing on a
cutter (Boat A) of Prefectural Youth Center as an outdoor activity lesson of the junior high school.
The wind and waves became so heavy that the crew then found it difficult to continue the rowing. At
around 15:25 when running southwestward off the south of Sakume in Lake Hamana, while being
towed by a motorboat (Boat B) of the Youth Center, Boat A capsized.
One of the students confined in the overturned boat died.

[Approx. 25 minutes before

the capsizing]
Boat B
The wind direction
changed southward, waves
became higher, and one of
the students got seasick:
the rowing became difficult.
Towing started

[Approx. 20 minutes before

the capsizing]
The teacher asked rescue Capsized
to Youth Center by radio. Boat A

[Approx. 10 minutes before Boat B Funaiwa triangulation

the capsizing] point
Boat B met Boat A, tied
their mooring ropes
together, and decided to tow
Boat A at a distance of 20 Planned course
m.

[Approx. 5 to 2 minutes
before the capsizing]
Boat B started towing
Boat A, which was listing to
port, and the bow violently [Capsized at 15:25]
repeated ups and downs The portside edge of Boat A subsided to allow massive inflow of lake
and allowed continuous water into her, Boat A overturned portside, two of the students and one of
inflow of lake water from the teachers were thrown out, and the other 16 students and one teacher
over the port bow. The were confined inside the boat of which 12 students and one teacher found
accumulated water on the their way out of the boat by their own effort. Rescue was made to them
portside bottom gradually later by an informed water rescue team, but one student confined in the
increased the port list. boat died.

Probable causes: The probable causes of this accident are as follows. Under rainy weather of which
heavy rain, thunder, gale, high-wave and flood advisories had been forecast, Boat A was used for an outdoor
exercise for the junior high school at the Youth Center and was engaged in a cutter rowing training without
a trainer along an east course, which is a usual way of the training, off the north shore of Lake Hamana.
The gale and wind grew stronger to render the rowing difficult, and the director of the Youth Center went
for rescuing on Boat B, and towed Boat A obliquely to port with continuous inflow of lake water thereinto
from the port bow. When being towed in those states southwestward off the south of Sakume, the Boat A's
port list developed under increasing flowed-in water accumulation on her bottom and caused the portside
oars to catch water and to turn her bow to port. Sometime later, the students sitting on the starboard side
lost balance and were shifted toward portside, to further increase the port list. Consequently, the port side
submerged, lake water flooded into the boat, and the boat overturned portside.

For details, please refer to the investigation report. (Published in Japanese on Jan. 27, 2012)
http://www.mlit.go.jp/jtsb/ship/rep-acci/2012/MA2012-1-8_2010tk0012.pdf

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3 workers, when handling copper sulfide concentrate, inhaled oxygen-deficient air and died.
Fatality of Stevedores Working on Cargo Ship SINGAPORE GRACE

Summary: This cargo ship was moored for discharging copper sulfide concentrate alongside the quay
in Saganoseki Port. At around 08:30 on June 13, 2009, one of the stevedore workers was stepping
down the ladder in the No.3 Hold to work, and fell down on it. Two of three workers who went to
rescue him also fell down in the Hold.
The three fallen workers were taken out of the Hold but eventually confirmed dead.

No.3 Hold

During the voyage, the copper sulfide concentrates in the

closed NO.3 Hold had oxidized, consuming the inside oxygen,
to turn the atmosphere*1 in the Hold oxygen-deficient. The
flotation reagent adsorbing onto the copper concentrates had
produced toxic odorous gases which, heavier than air, had
stayed there. Passage into the Hold
*1: "Atmosphere" means a state of a mixture of certain gases.

[Primary Accident] [Probable causes of Primary Accident (Abstract)]

When the ship was Worker A entered the No.3 Hold in which the atmosphere had
moored in Saganoseki Port, been oxygen-deficient, probably because a sign permitting entry
worker A entered the No.3 had been posted at the entrance to the Hold and because another
Hold, moved to its bottom, worker had been driving a heavy vehicle in the No.1 Hold
and died from oxygen
deficiency.

[Probable causes of Secondary Accident (Abstract)]

[Secondary Accident] It is somewhat likely that Worker B could not become aware of
In order to rescue oxygen deficiency in the atmosphere of No.3 Hold because he was
Worker A, 3 workers so absorbed in a sense of responsibility for rescuing Worker A and
entered No.3 Hold, and that he was upset. The cause of this accident may also partly lie
Worker B died from oxygen in the facts that there were some workers who thought that
deficiency (while the other oxygen deficiency in a cargo hold would be prevented by natural
two workers felt ventilation in the course of time if the hatch was kept open, and
suffocating and returned to that no measurement of oxygen concentration in oxygen-deficient
the deck). atmosphere had been made nor a fatal accident due to oxygen
depletion had occurred since the last accident that had took place
in a cargo hold 4 years before.
[Tertiary Accident]
Two workers wearing a
[Probable causes of Tertiary Accident (Abstract)]
gas mask entered No.3
It is somewhat likely that Worker C entered No.3 Hold wearing
Hold again, and one of
a gas mask because he thought a gas mask could be effective for
them, Worker C, died from
oxygen deficiency, that he, too, was so absorbed in a sense of
oxygen deficiency (while
responsibility that he was upset, and that the aftereffect of the
the other of them returned
oxygen depletion he had suffered when he had entered the Hold
up to near the hatch and
after the occurrence of the primary accident disabled him to make
was saved by crewmen of
an appropriate decision.
this ship.

For details, please refer to the investigation report. (Published on Apr. 27, 2012)
http://www.mlit.go.jp/jtsb/eng-mar_report/2012/2009tk0008e.pdf

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A tugboat capsized when towing a departing vessel, losing 2 lives.

Capsizing of Tugboat KITA MARU No. 12

Summary: When towing the patrol boat MIURA (Boat A) to assist her departure, together with the
tugboat KITA MARU No.8 (Boat C), the tugboat KITA MARU No.12 (Boat B) with a skipper and a
crewman aboard it capsized at around 07:36:47-54 on Sept. 19, 2011.
All the crew (2 crewmen) of Boat B were taken out of the water but died. On a later day, the boat
was salvaged but was declared a total loss.

③ North-
northeast /
northeast
Boat B capsized as the ② wind
tension of her towing At information 10 m/s
rope exceeded its from Boat A, Boat B
stability. The two towed Boat A while
crewmen were taken turning to port to
out but died. tow westward.

①
③ Toward the port When informed from
Boat A, Boat B thought it
entrance, Boat A
was 3 o'clock (066º) with
advanced at a speed ③07:36:47 reference to north.
of approx. 4.1 knots,
hard starboard, and
both propellers
ahead 10º pitch.
×
①07:28:11
② To stop the
backward
movement, Boat A
advised Boat B
"Tug toward 2 ②07:33:41
o'clock starboard", Boat C
and set the pitch
ahead 10º port and
ahead 6º starboard. Boat B

① Boat A advised
Boat B, "Tug bow
and stern toward 3
o'clock (approx. 016º
with reference to
heading direction).
Boat A

Probable causes: It is probable that when Boat B, along with Boat C, was towing Boat A to assist the
departure of Boat A from Wajima Port, with the towing rope tied at the bow of Boat A, under
north-northeast to northeast wind velocity of approx. 10 m/s and wave-height of approx. 3 m, Boat B
capsized because the tension of her towing rope exceeded her stability.

For details, please refer to the investigation report. (Published in Japanese on Nov. 30, 2012)
http://www.mlit.go.jp/jtsb/ship/rep-acci/2012/MA2012-11-1_2011tk0034.pdf

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A tanker listed, capsized and sank as seawater flowed in through air pipe of ballast tank
Foundering of Chemical Tanker SEIYO

Summary: When this tanker, manned with a master and 4 crewmen and loaded with approx. 1,000
tons of vinyl acetate monomer, which had left an anchorage off the Oita Airport, Oita Prefecture and
had passed off the Rokkosaki (Noto Peninsula), Suzu City, Ishikawa Prefecture, was heading
east-northeast toward Akadomari Port (Sadogashima), Sado City, Niigata Prefecture on Jan. 9, 2011,
she capsized and, at around 09:22, sank.
The chief engineer died and the master went missing.

Gross tonnage: 499 tons Weather & sea conditions when capsized
L x B x D: 64.8 x 10.0 x 4.5 (m) (at around 07:00):
Launched: December 2003 Wave height: 2.95 m; Wave cycle: 7.3 s;
Wave direction: 285º; Wind direction: 285º; Akadomari
Wind velocity: 12.3 m/s
Port
＋

Rokkosaki

At around 06:30,
Saruyama- Noto seawater flowed into
misaki At around 06:10, the air the fuel service tank,
Peninsula and the main engine
and filling pipe head* of
the air pipe of the port and then the power
ballast tank was generation engine
submerged in the water stopped.
repeatedly, and the At around 07:05, the
At around 04:00, ship capsized.
seawater flow into the
steady portside list At around 09:22, the
port ballast tank
and rolling ship sank.
At around 02:20, continued.
increased.
Seawater flooded
upon the port side of
the upper deck and
the expansion trunk
and remained there. * The "air and filling pipe
Seawater flowed head of the air pipe" is an
Disc float
into the ballast tank automatic closing device to
heeled the ship by block the inflow of waves, in
about 5º portside. which a disc float is designed
to shut out seawater inflow Sea
as it rises up. water
Air flow Water inflow preventer

Probable causes: It is probable that this accident occurred as follows. When this ship was sailing off
Saruyama-misaki toward Akadomari Port in a quartering sea from port side, the water inflow
preventive function of the air and filling pipe head of the air pipe of the port ballast tank failed to
function and allowed seawater to flood upon the port side of the deck and the expansion trunk and to
continuously stay. The seawater that flowed into the ballast tank increased the list of the ship to port
and caused to repeatedly submerge the air and filling pipe head of the air pipe. Flowed-in seawater
from the air pipe into the port ballast tank continuously increased the port list to consequently turn
over and sink the ship.

For details, please refer to the investigation report. (Published in Japanese on Dec. 21, 2012)
http://www.mlit.go.jp/jtsb/ship/rep-acci/2012/MA2012-12-1_2011tk0001.pdf

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A sightseeing boat on a river cruise ran aground and then capsized

0
Capsizing of Passenger Boat TENRYU MARU No. 11

Summary: When cruising down the river Tenryugawa with 2 boatmen and 21 passengers aboard on
August 17, 2011, this boat ran aground at around 14:17 on a rocky area on the left side of the bank of
the Tenryugawa at Futamata, Tenryu Ward, Hamamatsu City, Shizuoka Prefecture, and was
overturned, to take the life of four of the passengers and one of the boatmen and to injure five of the

Boatman on Boatman on With a total of 21

the bow the stern passengers aboard,
consisting of 14 adults
including a boatman on
the bow and a boatman
the stern, 1 junior high
Bow school pupil, 5 children
：Adult or JHS pupil
Stern
：Child or infant and 1 infant, this boat left
：Died ：Injured the embarkation pier.

It is probable that when this boat

天竜川

The course approached the water area of this

of the boat accident, the boatman on the stern started
the outboard motor at upstream of the
area and, at a central part of the rapids,
took a course to run by the right-hand side
of the swirling water without increasing
the outboard motor speed. As a result,
the bow was turned rightward by the
swirling water so much as it was directed
to face the right bank of the river.
×

It is somewhat likely that, with the

addition of repelling waves from the right
This accident bank, the boat bow might have been
occurred turned upstream.

It is probable that, having been brought in

an equilibrium between the pressure of
strong current from upstream and the
propelling force of the outboard motor, the
boat moved obliquely toward a rocky area
on the left bank side until the bottom of
the starboard bow ran aground a rock, to
incur port stern submergence and
Area around the overturn.
accident site

Swirling
water

Probable causes: It is probable that this accident occurred as follows. While cruising down along the
route on the river Tenryugawa, this boat deviated her course from the center to the right-hand side of
the swirling water which had arisen in the water area of this accident and was forcibly turned toward
upstream direction. The boatman on the stern then increased the propeller speed by the throttle of
the outboard motor, to bring about equilibrium between the pressure of strong steam from upstream
and the propelling force of the outboard motor. In the equilibrium, the boat could not turn her bow
upstream due to the strong downstream at the left bank side but was obliged to obliquely move toward
a rocky area on the left bank side and to run aground the rock. Submergence started from her port
stern and the boat was overturned.

For details, please refer to the investigation report. (Published in Japanese on Dec. 21, 2012)
http://www.mlit.go.jp/jtsb/ship/rep-acci/2012/MA2012-12-3_2011tk0026.pdf

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