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Singapore TSIB Report Highlights Crew Fatigue in Fatal Collision.

Occurrence Overview

On 19 July 2024 at about 0602H, a collision occurred in the South China Sea, east of Malaysia, between the Singapore-registered oil/chemical tanker Hafnia Nile and the São Tomé and Príncipe-registered tanker Ceres IHafnia Nile was underway on a northeast-bound passage, while Ceres I was at anchor. Weather conditions were fair, with good visibility, fresh winds of 15 to 25 knots, and a north-westerly current of 2 to 4 knots.

The collision caused structural damage to both ships and resulted in the loss of bunker fuel and naphtha cargo from one of Hafnia Nile’s cargo tanks, leading to a fire on both ships. Two shore workers onboard Ceres I sustained serious burn injuries, and one later died in hospital. The occurrence was classified as a very serious marine casualty.

Bridge Watchkeeping and Navigation

During the 0000H–0600H watch, Hafnia Nile was navigating in close proximity to several targets. The Officer of the Watch, the Second Mate, left the wheelhouse to prepare reports, leaving an Able Seafarer Deck alone in the wheelhouse. 

The CPA and TCPA alarms on Hafnia Nile’s radars were silenced or deactivated, removing audible alerts that would normally assist in identifying developing close-quarters situations. As a result, detection of collision risk relied on visual lookout and manual radar observation.

Hafnia Nile attempted to navigate between Ceres I and another southwest-bound ship that were approximately 0.7 nautical miles apart. At the time, the Second Mate was in the chartroom, separated from the wheelhouse by curtains during hours of darkness.

Human Element and Fatigue

The Second Mate of Hafnia Nile had joined the ship after overnight travel with limited rest. After joining, he was involved in port activities and experienced disrupted rest prior to commencing the midnight watch. At the time of the collision, he had obtained about two hours of rest over a 38.5-hour period.

Actions on Ceres I

The bridge team on Ceres I detected Hafnia Nile at a range of 6.4 nautical miles and initially assessed the risk as low. Visual and sound signals were reportedly used to warn Hafnia Nile, but these were not acknowledged. VHF radio was not used when the situation escalated to close quarters.

Ceres I’s Safety Management System required bridge teams to warn approaching ships but did not specify the methods to be used. No human element issues were identified on Ceres I.

Bridge Manning Levels

An incidental observation identified that Hafnia Nile did not meet its company Safety Management System bridge manning level requirements during departure and part of the transit through the Singapore Traffic Separation Scheme. At the time of the collision, the bridge manning level met the company requirement.

Safety Actions by Hafnia Nile Company

Following the occurrence, Hafnia Nile’s company implemented safety actions addressing bridge watchkeeping, fatigue risk management, bridge resource management, and situational awareness. Measures included revisions to crew travel and rest arrangements, reinforcement of watchkeeping standards, restrictions on non-operational computer use on the bridge, enhanced navigation training, leadership initiatives, and planned unannounced VDR audits throughout 2025.

Ceres I’s company reported that no safety actions were taken following its internal review.

Safety Recommendations

Safety recommendations were issued to:

  • Ensure CPA and TCPA alarms remain active and are systematically reviewed during passage planning and watch handovers.
  • Reinforce adherence to prescribed bridge manning levels and document any justified deviations.
  • Provide clear Safety Management System guidance on the use of communication tools, including sound signals, light signals, and VHF radio, during developing close-quarters situations.

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