Modalités de l'enquête de sécurité
Dans le domaine des transports maritimes, une enquête technique doit être réalisée chaque fois qu'un accident de mer entraîne:
- la perte totale du navire, ou
- des pertes en vies humaines, ou
- des dommages graves à l'environnement.
Les définitions détaillées et autres dispositions régissant une enquête de sécurité dans le domaine des transports maritimes peuvent être consultées dans les différents textes et documents législatifs dans la rubrique législation, sous-rubrique transports maritimes.
Rapports finaux à destination du public
Rapports publiés par l'AET en qualité d'autorité responsable de l'enquête
Fatal occupational accident on board of the vessel Willem De Vlamingh on 9 October 2021
On 9 October 2021, on board the Willem De Vlamingh, a multipurpose and support vessel, berthed in the Port of Anping (Taiwan) a crew member was found trapped in a Power Operated Sliding Watertight Door (POS-WTD) at around 17:30 (Local Time). The crew member was brought ashore and was pronounced deceased at a local hospital.
The ongoing investigation of this fatal occupational accident has highlighted a safety issue that required an immediate safety action.
The following safety recommendations were issued on 4 April 2022:
SAFETY RECOMMENDATION LU-MA-SR/2022-001 (PDF) SAFETY RECOMMENDATION LU-MA-SR/2022-002 (PDF)
Sinking of the vessel Bourbon Rhode on 26 September 2019
On 17 September 2019 at 22:36 UTC, the Offshore Deep Water Anchor Handling Tug Supply (AHTS) vessel Bourbon Rhode left the port of Las Palmas, Gran Canaria (Spain) after extensive service and maintenance works in a local shipyard. The destination was Georgetown (Guyana), where a new contract was scheduled to start at the beginning of December 2019.
The transit voyage was uneventful up to the afternoon of 25 September 2019, when the vessel entered an area of tropical storm force winds associated with hurricane Lorenzo.
In the morning of 26 September 2019, at 07:50 UTC, the Ship security alert system (SSAS) transmitted an alert message via Inmarsat-C which was first received by the Joint Rescue Coordination Centre (JRCC) Stavanger, Sola (Norway). A distress message was then sent by Digital Selective Call (DSC) and was received by the Maritime Rescue Coordination Centre (MRCC) in Madrid (Spain) at 08:03 UTC. The Emergency Position-Indicating Radio Beacon (EPIRB) on the Bourbon Rhode was activated by the crew and the signal was received at 08:06 UTC by the French mission control centre (FMCC) in Toulouse (France) via a MEOSAR satellite. At 08:45 UTC, the Master reported to the Bourbon Offshore Greenmar (BOG) ship manager by Inmarsat-C text message that the vessel was sinking, with water in the engine room.
The vessel was located in the West Indies sector where the MRCC Fort-de-France, Martinique (France) was in charge of search and rescue (SAR) operations. At 09:18 UTC, the MRCC Fort-de-France launched the active SAR operations with a call for assistance to the bulk carrier SSI Excellent, located approximately 200 NM to the south of the Bourbon Rhode’s position. At 12:43 UTC, the last position received from the vessel’s Satellite-Automatic Identification System (SAT-AIS) was 15°35.383’ N, 040°12.783’ W. The EPIRB continued transmitting signals that were received by the Cospas-Sarsat system until 13:50 on 30 September 2019.
During the SAR operations, three survivors and the bodies of four crew members were recovered. At the time of publication of the interim report, seven crew members were still missing.
- The ongoing investigation of the sinking of the vessel Bourbon Rhode on 26 September 2019 in the Atlantic Ocean during a transit voyage from Las Palmas to Guyana has highlighted a safety issue that required an immediate safety action.
The following documents were issued on 19 August 2020:
Safety recommendation (PDF) Safety bulletin (PDF)
- The following press release was published on 28 September 2020:
Press release (PDF)
- Le communiqué de presse suivant a été publié le 28 septembre 2020:
Communiqué de presse (PDF)
- The following interim safety investigation report was published on 15 April 2021:
Fatal occupational accident on board of the vessel MV Medi Zuoz on 4 April 2019
On 3 April 2019, the bulk carrier MV Medi Zuoz dropped anchor at number one anchorage area at Iskenderun, Turkey (TK), after having discharged mixed metal scrap at Iskenderun port.
A cleaning team boarded the ship to clean all the cargo holds before the vessel was scheduled to continue its voyage to the next loading port. The company executing the cargo hold cleaning used two scaffolding towers (5 ‘lifts’) to reach the upper parts of the holds during the cleaning process.
The next day, on 4 April 2019, the hold cleaning was continued and the assembled scaffolding tower was to be moved as a whole from one cargo hold to the next by crane with the ropes connected to lift the tower. After the scaffolding tower was lifted, the deck crew noticed that the structure appeared to be unstable and the tower was put back on the tank top.
A shore contract worker climbed up the scaffolding tower to properly attach the ropes to the crane so that the tower could eventually be moved to the next hold. While climbing up the scaffolding tower, the unsecured contract worker lost balance, fell on the tank top and was seriously injured. It was later established that one of the two ropes used to connect the tower to the crane hook had broken.
The accident was immediately reported and emergency actions taken to transfer the injured worker to shore and hospital. The worker was declared dead at a nearby hospital.
Based on the findings of the safety investigation, two recommendations were issued by the AET.
Fatal occupational accident on board of the vessel Nabucco on 26 June 2017
On 26 June 2017, at 19:20, the chemical oil tanker Nabucco was all fastened and berthed port side alongside Associated British Ports (ABP) Terminal number 1 jetty in Saltend, Hull, United Kingdom (UK). Two means of access were established. One gangway was installed to enable access in low water situation and the port side accommodation ladder was established for high water situations.
At around 22:50 the means of access were required to be changed as the tide was on the ebb and the accommodation ladder needed to be stowed away. The gangway was prepared for accessing the vessel.
The Chief Officer was working alone on the platform of the accommodation ladder and at 23:03 he fell from the accommodation ladder platform between the vessel and the quay into the water.
Despite intense search actions, the body of the Chief Officer was only discovered on 5 July 2017 some 30 km downstream.
Based on the findings of the safety investigation, one recommendation was issued by the AET.
Fatal accident on board IBN Battuta on 29 September 2011
On 1 March 2011, the cutter suction dredger (CSD) IBN Battuta arrived in Vietnam for a dredging project located in Vung Ang – Ha Tinh, 350 km South of Hanoi.
Due to the forecast tropical storm NESAT, the vessel interrupted the ongoing dredging project and departed on 28 September 2011 for the port of Da Nang in the South of Vietnam. In the morning of 29 September 2011, the vessel dropped anchor in the port of Da Nang. While the vessel was at anchor, the deck crew (including the Apprentice Dredge Operator) was painting the walls of the pump room, as part of regular maintenance.
At 10:05 AM, the Apprentice Dredge Operator, presumably on his way to join the deck crew for a coffee break, was found stuck in the power operated sliding watertight door (WTD) between the pump room and the engine room. At 10:35 AM, after being transported ashore, the Apprentice Dredge Operator was declared dead at quay by a doctor.
Based on the findings of the safety investigation, three recommendations were issued by the AET.
Fatal accident on board Juan Sebastian de Elcano on 3 November 2014
On 22 October 2014, the vessel dropped anchor at 05:05 PM LT in Manila Bay, at position 14.55° N, 120.94° E. While at anchor, the crew was performing regular maintenance tasks and some preparation for the next docking.
On the day of the occurrence, the deck crew took part in a daily Pre-Start Meeting (PSM) at around 06:00 AM, discussing the tasks for the day. One of the tasks was to perform thickness measurements of the hopper walls, side, fore and aft plates. The 2nd Pipe Operator (day shift) and the Apprentice Pipe Operator, both attending the PSM, were assigned to the task.
First, the hopper was filled with water after the aft overflow was blinded off and the fore overflow set at 11.82 m. A small boat was then lowered into the hopper and the crew assigned to the task entered the boat with their equipment. After the first set of measurements, the unsecured boat with both occupants was located at the aft starboard (SB) part of the hopper. After radio co-ordination with the Chief Officer on the bridge, the water level was lowered for the next level thickness checks.
While the water level was being lowered, the crew in the boat tried to paddle to the front port side (PS) of the hopper, but the strong current caused by the outflowing water made the boat bump against the overflow. At that point, according to the statement of the 2nd Pipe Operator (day shift), the Apprentice Pipe Operator stood up to grab for a hold. The boat became unstable and flipped over. Both occupants fell into the hopper and got pulled down through the overflow. The 2nd Pipe Operator (day shift) exited under the vessel’s hull and managed to swim to the surface, where he was subsequently rescued. Unfortunately the Apprentice Pipe Operator was missing. His floating body was found the following day close to the ship near the trunnion gantry.
Based on the findings of the safety investigation, one recommendation was issued by the AET.
Rapports étrangers publiés où l’AET a été associée à l’enquête de sécurité
Collision between FV Z.575 – HEIN SENIOR and MV ACEROMAR on 3 August 2020
On August 3rd 2020, at 04:02 hours, the Belgian flagged beam trawler Z.575- HEIN SENIOR collided with the Luxembourg flagged general cargo vessel mv ACEROMAR. The collision occured inside the traffic separation scheme Terschelling-German Bight, approximately 16nm NxW off the North Tower lighthouse on the isle of Schiermonnikoog.
After the collision the mv ACEROMAR was damaged on PS, above the waterline, from for’d of the beam to the aft. Some side shell plating, deck plating, railing and bulwark was bent. The hatch cover gantry crane was damaged by the PS derrick of fv. Z.575-HEIN SENIOR. Fv Z.575-HEIN SENIOR was ripped open on her PS bow, above the anchor lock, over a length of approximately 5 metres. The PS derrick of fv Z.575-HEIN SENIOR was smashed against the wheelhouse after it had hit mv ACEROMAR.
After contact with the Dutch Coast Guard, fv Z.575-HEIN SENIOR returned to her port of departure, Lauwersoog, and mv ACEROMAR continued her voyage to the port of Rotterdam.
Fatal accident on board mv Simon Stevin on 28 January 2019 at the Port of Zeebrugge
The subsea rock installation vessel mv SIMON STEVIN was moored alongside at the Port of Zeebrugge for overhauling purposes. On Monday, January 28th, tests of the fall pipe system were planned as maintenance of the system had been finished.
At 17.55, a steel pipe section was lifted by the gripper and transferred to the manipulator of the gantry crane to drop off the pipe in a dedicated storage position. Around 18.00, the manipulator failed to put the steel pipe back in the brackets at the storage position, so the first operator used the belly box remote control to overrule the automated process and to position the pipe in the guide brackets.
The operator was walking backwards to keep a visual on all the components of the gantry crane diagonally above him while it was moving towards the waiting position. The operator didn’t notice that he was approaching the opened gate behind him and he fell down onto the main deck.
Contact with wharf by livestock carrier Angus Express at Broome, Western Australia, 20 April 2018
At about 0600 Western Standard Time1 on 20 April 2018, the 103 m livestock carrier Angus Express arrived at the Broome, Western Australia, pilot boarding ground.
By 0710, the ship was alongside the wharf, with two Yokohama fenders4 positioned forward and aft, between the ship and wharf’s vertical fender posts. The ship was about 8 m aft of its berthing position at berth 4 and 5, when mooring lines were run to the wharf. The pilot then tried to use the mooring winches to heave in the mooring lines to move the ship forward into position.
At 0712, the weight of the ship against the forward Yokohama fender forced it to pass under the fender posts, which resulted in the ship’s bow moving towards the wharf. Shortly after, an overhanging scupper5 protrusion made contact with the fender post (about 30 m from the ship’s bow).
Grounding of Bosphorus, Brisbane River, Queensland, 29 October 2013
At about 2000 on 29 October 2013, the general cargo ship Bosphorus grounded at Lytton Rocks Reachin the Brisbane River after the ship’s helmsman unintentionally put the helm the wrong way. By the time that the Brisbane Marine Pilot on board the ship realized that the helm had gone the wrong way, it was too late to prevent the ship from grounding in the narrow section of the river. There were no reported injuries, damage or pollution as a result of the grounding.
Rapport d’enquête technique, rupture du mât du catamaran Allures, 19 juin 2011, Haute-Corse
Alors que le capitaine contrôle le réglage des voiles et la tension dans les haubans(à partir d’un écran multifonctions du poste de barre),un violent craquement se fait entendre, instantanément suivi de la chute du mât dans l’eau,et de la bôme sur le flybridge. Le capitaine est prisonnier sous la voile mais se dégage rapidement pour évaluer la situation:le second, qui se tenait appuyé au caisson tribord, à proximité du poste de barre,est mortellement blessé par la bôme.