16 th June 2006 File No. 26206 This Report has been presented without prejudice and with the exercise of due care and diligence. In accepting this report of Certificate, it is agreed that the extent of the obligation of this firm with respect thereto is limited to furnishing a Surveyor believed to be competent, and in making this Report or Certificate, the Surveyor is acting on behalf of the person requesting the same, and no liability shall attach to this Firm for the accuracy, errors and omissions thereof. CASUALTY INVESTIGATION REPORT ( Investigation of Death @ Sea ) M.v. “ NYK SPRINGTIDE ” Voyage :- 32E17 YIT Terminal @ Los Angeles, California 12 th May to 7th June 2006
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Marine Casualty: the death of a person that is caused by, or in connection with, the
operations of a ship.
6.2 Date, Time and Place of Incident
The incident (apparent loss of a person over the side) took place at sometime
between the hours of 03/1000Z (when Mr. Shah was last seen) and 03/2030Z
(when it was discovered that he was missing).
6.3 Details of Incident and of the Events Leading Up To It and Following It
During the last day that Cadet Jai Shah was seen on the vessel, he worked (under
the direction of the Chief Officer) with the Bosun cleaning in cargo hold bilges.Following that work he was assigned by the Chief Officer to monitor the ballasting
of a tank in the Ballast Control Room as the tank filled by gravity. He reportedly
stopped the operations below the tank top level. He reportedly informed the Chief
Officer (via ships telephone to the Bridge) when this was completed at
approximately 03/1730 LT (03/0630Z). He was told by the Chief Officer to “knock
off” and get dinner. He was told to start work again in approximately two hours
(1940) to make a fire round of the interior areas of the ship.
Following his fire round, Cadet Shah reportedly came to the Bridge to make atelephone call to India. This happened at approximately 2045 (LT). During this
time period, ships clocks were being moved forward 20 minutes per watch. The
Third Officer was on the Bridge at this time. Another Crewmember was using the
phone at the time. Cadet Shah reportedly told the Third Officer that he would go
below for a few minutes and come back when the phone was free.
Cadet Shah reportedly came back to the Bridge and made his phone call to a family
friend in India. The ships phone records show that this call was made at 03/2136Z.
This would have been at approximately 03/2100 LT. The Third Officer reports that
he did not overhear any noticeably loud or stressed conversation during the phonecall. He reported that Cadet Shah came onto the Bridge (from behind the blackout
curtain) and wished the Third Officer a good night. When the Third Officer
returned good night wishes, Cadet Shah left the Bridge. According to internal
interviews with all crewmembers by the Master and Chief Officer (and confirmed
by the Investigator), that was the last time that anyone on the ship saw Cadet Jai
During the night, the records do not indicate any incidents. The Chief Officer
reports that all crewmembers (including Cadet Shah) were warned about heavy
weather, and told not to go out on deck. There is a notation in the deck logbook
that “Checklist for navigating in heavy weather completed with rough seas and
swell.” A copy of this checklist is included in this report. It is noteworthy that
there is no requirement for the posting of signs on all internal doors warning
about not going on deck during heavy weather.
On the following morning, the first official notice of Cadet Shah being missing is
in the statement of the Chief Officer. He states that he was informed at 0815 hours
by the Bosun that the Cadet had not reported for work. The Bosun stated that he
had called the cabin of the Cadet (10-15 rings) with no reply. The Chief Officer
then went to the cabin. He found the door open, went inside, but did not find the
Cadet there.
The Chief Officer then went to ask the crew directly if they had seen the Cadet. At0830 the Chief Officer informed the Bridge (and the Master) that the Cadet was
missing. At that time, a search was begun with the Chief Officer, Bosun and deck
gang. When the Cadet was not found at 0900 the General Alarm was raised, the
crew mustered, and a head count showed the Cadet as still missing. A full-scale
intensive search of the vessel from bow to stern was then launched with all hands.
This was the first of four such searches during that day. At 1028 the vessel was
turned to a reciprocal course to head back towards the last position when the cadet
had been seen.
The ocean search for the missing Cadet Jai Kumar Shah took place over the next
33 hours. Communications took place with Company officials, and with the USCG
providing SAR assistance. The details of the ocean search follow with times in
UTC:
• 03/2110 Phoned NYK Cell Manager Mr. Chadha to inform of the incident
• 03/2200 Completed physical search of vessel
• 03/2226 Received call from Capt. Nakaya of NYK who told to reverse
course
• 03/2228 Reversed to reciprocal course to return to last known position
• 03/2230-2400 Conducted a second search of vessel for missing Cadet
• 04/0100 Commenced third search of vessel for missing cadet
• 04/0100 Received phone call from Mr. Richards of USCG RCC Honolulu.
Informed that 2 aircraft had been dispatched (from Honolulu and Alaska)
• 04/0155 Informed by RCC Honolulu that C-130 aircraft would search the
• 04/0500 Received call from NYK Captains A Singh and Joshi asking for
telephone numbers for cadet.
• 04/0518 Informed by RCC Honolulu (Lt. Taylor) that SAR aircraft would be
over the area and stay on site for approximately one hour
• 04/0600 Commenced fourth physical search of the vessel
• 04/0730 Darkness setting in. Search suspended. Proceeded to position of last
sighting to resume search at daybreak
• 04/0900 Informed passing vessel MV TANGO of missing crewmember and
asked to keep sharp lookout
• 04/1015 Informed by RCC Honolulu that due to fuel constraints, aircraft
were returning to their home stations
• 04/1740 Resumed search for missing cadet in position 38-333.5N 171 38.9E
in parallel search pattern
• 05/0145 Informed by USCG RCC Honolulu that they were suspending
search
• 05/0730 As darkness fell, suspended the search for missing crewmember
Cadet Jai Kumar Shah, and resumed voyage to Los Angeles, CA
6.4 Details of the Performance of Relevant Equipment
There is no evidence of any equipment failures relevant to the incident. However,
it will be noted in another section of this report that a chain link rail was not in
place over the port bunker rail (located just aft of the Accommodation House), andthe chain over the starboard bunker rail did not have proper tension, and added
little height to the rail at that position.
6.5 Persons on Bridge
During the time period in which the incident apparently took place, the Bridge was
manned by a Watch Officer (3rd
Officer, 2nd
Officer and Chief Officer) and a
lookout.
6.6 Persons in Engine Room
During the time period in which the incident apparently took place, the engine
room was in UMS condition and unmanned. Security rounds were made
periodically of the area, but Cadet Shah was not seen in the Engine Room.
The strong winds and large seas during the time that Cadet Shah went missing
made it extremely unlikely that Cadet Shah would be found if not one actually saw
him go over the side. It is virtually certain that the only other person outside during
this time period would have been the lookout on the Bridge wing. The fact that the
wing is 20 meters above the main deck and 30 meters above the ocean; combined
with the noise of the wind would make it virtually impossible for any outcry from a
person going over the side would be heard on the ship.
11 Recommendations
It is apparent that all crewmembers on the NYK Springtide are devastated from the
loss of a friend and fellow crewmember. It is also apparent that Cadet Shah was
well-supervised during his working hours on the ship. There is no reasonable way
that any crewmember (even a young and inexperienced one such as Cadet Shah)
can be watched and supervised 24 hours a day. However, it is the opinion of the
Investigator that the two Ship Factors noted in the previous section should be
addressed. His recommendations follows:
• Chain rails over the rounded bunker rail should always be replaced before a
vessel leaves port. These chains should be stretched tightly over this space
so that the effect is to have a rail at the same height as the rest of the railing
on the main deck.
The Company should institute a requirement that all interior doors which lead to
the outside (at all decks) should have warning signs placed on them during periods
of heavy weather. The placement of these warning signs should be a requirement
of the “Heavy Weather Navigation Checklist.”
Summary
Casualty Investigation of M/V NYK Springtide
The container vessel M/V Springtide suffered the loss and presumed death at sea of
a crewmember during the evening of May 3rd
, 2006. May 3rd
was a repeated day on
the vessel as it transited Eastbound across the Pacific and the International DateLine. The vessel was enroute from Sendai, China to Los Angeles, CA on Voyage
32E17 and approaching the International Date Line at position 38 42.0N 176 26.0E
at 0830 LT (03/2030Z) when it was discovered that Cadet Jai Kumar Shah had not
reported for duty.
After an unsuccessful physical search of the vessel and consultation with Company
and other officials, at 1028 LT (03/2228Z) the Master ordered the ship to be turned
around to go back over the course traveled during the previous night and begin an
ocean search of the waters traveled. A total of four complete physical searches of
the entire vessel were conducted over the course of the day. The ocean search of
the waters traveled, and a parallel ocean search under the direction of the USCG
Search and Rescue (SAR) unit was conducted until searching was abandoned as
darkness fell on the second search day on 4 May 2006 at 1930 LT (05/0730Z).
Interviews with the Master and a number of crewmembers indicate that the last
time anyone saw Cadet Shah on the ship was at approximately 02/2100 LT
(03/2140Z) on the bridge where he had made a ship-to-shore phone call to a friend
in India. Thus, there was a period of more than 11 hours in which his whereabouts
were unknown.
The vessel was in relatively heavy weather during the night of the disappearance,
with winds from the SE at force 7 increasing to force 8 from the south during the
night. A log book entry during the 00-04 watch indicates that the vessel completedthe checklist for maneuvering in heavy weather. There are no other log book
entries as to heavy weather procedures; however the Master and Chief Officer
indicate that verbal warnings were given to crewmembers not to go on deck during
the night. The ship apparently does not use warning signs on the doors to attempt
to prevent anyone from going out on deck.
During the investigation, we reviewed all relevant documents, charts, and records,
and conducted a thorough inspection of the ship from the Navigation Bridge
(where Mr. Shah was last seen), to Mr. Shah’s cabin, inside and around the outsideof the Accommodation House of the vessel, around the Main Deck, and through
the entire system of port and starboard tunnels. We also conducted interviews with
the Master, Chief Officer, 3rd
Officer, Bosun, and the FMA (Fitter Assistant) who
was known to be the best friend of Mr. Shah on board.
There are four possible conclusions to draw from a person missing on a ship at sea:
• The person committed suicide (planned or unplanned)
• The person was the victim of foul play
• The person was hidden away on board, not found, and managed to leave the
ship un-noticed when it reached port
• The person met with an accident while out on deck and was washed (or fell)
over the side
It is the conclusion of this investigation that Mr. Shah is missing and presumed
deceased. The most likely occurrence of the four possibilities listed above is that
Cadet Jai Kumar Shah mistakenly went out on deck and accidentally went over the
During the time period when the whereabouts of Mr. Shah became unknown, the
deck officer on the bridge was operating inside the wheelhouse. The lookout was
on the wing of the bridge, but due to the noise of the wind and the distance above
the water, the chances of the lookout hearing any shout from a person going over
the side would be highly unlikely. The exact cause which led Mr. Shah to leave his
cabin at night to go out onto a dark and windy deck in the dark will likely never be
known.
The temperature of the water at the time is this incident was listed in the ship
logbook as 15 degrees Celsius. All of the survival gear on the ship was reported to
be in place by the Master and ships officers. Given this situation, the amount of
time that a person could be expected to survive in the sea would certainly be less
than 2 hours, and would likely be measured in minutes. The sea was also quite
rough during this time period.
The Master conducted a search of the waters where Mr. Shah could most likely beexpected to be found for approximately 33 hours, and with consultation with SAR
officials, it appears to have been a reasonable decision to abandon the ocean
search, and reach the inescapable conclusion that Mr. Jai Kumar Shah had perished
During his time as a deck officer and ship master, Capt. Breese transited every ocean in
the world, making port calls in Asia, Africa, Europe and North America. His primaryfocus was in the Pacific Basin, with dozens of trans-Pacific crossings. His time as Master
was spent on large containerships, but he has also sailed as a deck officer on CrudeCarriers, Product Carriers, Bulk Carriers, Break Bulk ships, and Passenger Vessels out of
all major ports on the U.S. West Coast and to Japan, Taiwan, Korea, the Philippines, andSingapore. As Master he made more than 100 transits of the treacherous Straits of
Malacca.
As a safety, quality, environmental and security auditor of merchant ships, Capt. Breese
has evaluated the working practices of seafarers from around the world. He has
participated in dozens of ride-along audits where he has been able to consult and advisecaptains, mates and engineers on the latest and best practices of seafarers. His primary
focus has been on bridge-team management, and operation of an effective bridge. He hasevaluated maintenance programs, including computerized preventive maintenance
programs, and has evaluated the operation of cargo, ballast, and stability systems on all of
the ships he has visited. He has also trained hundreds of mariners in the principles of safety and quality operations, and the use of management systems to improve shipboard
life.
Management of projects has been his focus for the past 4 years. His recent work includesa security gap analysis for the country of Jordan, and the development of security
processes for Exxon Mobil for their FPSO fleet. He is a certified lead auditor in ISM, ISO
9001 and ISO 14001, and has developed safety management systems for maritimeterminals and ships. He has extensive experience with Oil Spill Cleanup exercises and
plans, have my 40 hours hazmat certification, and fully trained in ICS.
Capt. Breese has a bachelor’s degree in Broadcast Journalism. This has assisted him in
his writing, training, and his ability to speak in front of large groups. Capt. Breese is
married, with two grown children. He lives with his wife in Fountain Valley, California.
Captain Breese was a Subject Matter Expert as part of a team that developed a Port
Security Assessment Tool for the USCG shortly after 9/11/2001. Following development
of the tool, he participated in security assessments at the ports of Philadelphia, SanDiego, and Portland, OR.
Capt. Breese has conducted safety and security assessments on ships and at facilitiesaround the world. Capt. Breese developed methodology for vulnerability and risk
assessments of U.S. flag and international vessels, as well as ports and port facilities. He
either led teams, or participated in investigations and audits for the following:
• Matson Navigation vessels
• Matson Navigation Hawaii Port Facilities
• Alaska Tankers Fleet
• Louis Dreyfus fleet vessels• Offshore Marine Service Association vessels (more than 200)
• Exxon Mobile’s Kizomba A FPSO
• Port of Gothenburg
• Port of Aqaba, Jordan
• Ports of Oman
• Ports of Nigeria
• Victoria Ship Management vessels
• Penn Terminals, Philadelphia, PA
• Chemoil Terminals, Long Beach, CA
Capt. Breese has conducted dozens of audits of port, port facility, and vessel security
plans around the world, and has trained more than a thousand persons to becomeSSO/VSO, CSO, and PFSO under the requirements of the IPSPS Code.