Cypress: Beverley II
Cypress: Beverley II
Beverley Ann II
Cypress Pass
12 miles south-east ofthe River Tyne breakwaters
on 9 March 1999
SYNOPSIS 1
1.1 Particulars 4
1.1.1 Vessel details 4
1.1.2 Accident details 4
1.2 Narrative 5
1.3 Environmental conditions 6
1.3.1 Weather 6
1.3.2 Tidal stream 7
1.4 Beverley Ann II 7
1.4.1 The skipper 7
1.4.2 The boat and fishing practices 7
1.4.3 Life saving appliances 7
1.4.4 Radar reflectors 8
1.4.5 Damage 9
1.5 Cypress Pass 9
1.5.1 The master and crew 9
1.5.2 Navigational practices and documentation 11
1.6 Post incident forensic examination 12
1.7 Status of the vessels with regard to the collision regulations 14
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SECTION 2 ANALYSIS 15
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SECTION 3 CONCLUSIONS 20
3.1 Findings 20
3.2 Causes 21
3.2.1 Immediate cause 21
3.2.2 Contributory causes 21
3.3 Other findings 22
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SECTION 4 RECOMMENDATIONS 23
GLOSSARY OF ABBREVIATIONS AND ACRONYMS
cm centimetre
G Gyro
kg kilogram
kW kilowatt
m metre
T True
Cypress Pass was on passage from Amsterdam to Jarrow Slake on the River Tyne,
making good a speed of 15.7 knots and steering (G) to make a course of
(T). On the bridge, keeping watch, were the master, the third officer and a lookout.
The visibility was between 1 and 2 miles, which was further reduced in squalls.
Beverley Ann II, crewed by the skipper and a deckhand, was trawling at a speed of just
over 2 knots and heading in an east-south-east direction. The skipper saw a large echo
appear on the edge of the radar screen at 3 miles but he did not make a full appraisal of
the risk of collision. The radar had only limited facilities with which to determine if the
vessel was on collision course. M e r a while, the skipper saw a ship very close on his
starboard bow and he could see down both sides of the ship. In an attempt to avoid a
collision, he stopped and then reversed both engines. However, the port bow and the
mast of the fishing vessel made contact with the port shoulder of the ship. Damage to
the fishing vessel was slight.
Once the fishing vessel had passed down the port side of the ship and had cleared the
stem, the skipper called Tyne Tees Coastguard to report the incident. The skipper said
that his vessel was not in immediate danger and that neither he nor his deckhand were
injured. He then called Cypress Pass and told the watchkeepers that their vessel had
been in collision. Up to this point, the officers had been totally unaware of the presence
of'BeverleyAnn II and that any incident had occurred.
Cypress Pass continued on to the anchorage off the River Tyne and Beverley Ann II
returned to North Shields.
Beverley Ann II - the skipper did not make a full appraisal of the risk of collision
when the echo of Cypress Pass appeared on his radar screen, and took no avoiding
action until the ship appeared at short range bearing down on him.
Cypress Pass - the officers and lookout did not observe the fishing vessel either by
radar or visually, and were therefore not keeping a proper lookout.
1
SECTION 1 - FACTUAL INFORMATION
1.1 PARTICULARS
Flags UK Liberia
4
1.2, NARRATIVE
Cypress Pass left Amsterdam at 1548 on 8 March 1999 and sailed for the
Nissan berth at Jarrow Slake on the River Tyne. At 0700 on 9 March, the
master was called after having had a full night's sleep. Shortly afterwards, he
arrived on the bridge and called Tyne Pilots on VHF radio to tell them that his
ship would be arriving off the River Tyne in two hours' time. He also tried to
call the Nissan berth controllers at Jarrow on VHF radio to advise them of his
estimated time of arrival (ETA), but experienced difficulties in making contact.
Tyne Tees Coastguard intercepted the call and said that they would relay his
message to Nissan.
At 0800, the third officer relieved the chief officer and a new lookout took
station on the port bridge wing. At 0815, with one hour to run to her final
waypoint off the Tyne, the master told the third officer that he was taking over
command and that the engine room should be given one hour's notice for
manoeuvring.
Both radars were in operation on the 6-mile range scale and in the true motion,
north-head-up mode. At 0830 the master called Tyne Port Control on VHF
radio and was told that he would have to anchor off the river and the ship
would berth later that evening. The third officer called the bosun to go forward
and prepare the windlass for anchoring. The bridge controls for the engine
were tested at this time.
That morning Beverley Ann II left North Shields at about 0630 for the fishing
grounds 9 miles south-east of the Tyne breakwaters. The fishing gear was shot
away at about 0745, and the skipper and his deckhand remained in the
wheelhouse during the tow. The boat was being steered manually and she was,
within one point, making a course of east-south-east at a speed of between 2
and 2.5 knots.
The radar was on the 3-mile range scale and in a head-up, unstabilised mode.
There was an echo, which the skipper assumed to be another fishing vessel, on
his port bow at a distance of about 3 miles. A new large echo appeared on the
starboard bow and was approaching rapidly. The skipper was unable to see the
vessel because of the reduced visibility (see section 1.3). There was only an
5
electronic bearing marker (EBM) (see section 1.4.2) on the radar to determine
whether the echo was on a steady bearing. After a while, the skipper saw a ship
appear out of a squall about 0.5 miles away. He could see both bows and down
each side of the ship. Although both engines were not quite on full ahead, he
thought that because he was towing, an increase in engine speed would make
little difference in moving ahead. If the ship passed close astern, the skipper
feared that his gear would be caught by the ship and that his vessel would be in
danger of being dragged down. He decided to stop and then reverse both
engines.
The fishing vessel collided with the ship's port bow shoulder in way of her port
bow comer. She was turned to starboard by the impact and then ran alongside
the ship's port side, during which time the mastwas damaged. Then Beverley
Ann II cleared the stem of Cypress Pass.
At 0855, after finding that his boat was not taking in water, the skipper called
Tyne Tees Coastguard on VHF radio channel 16 and told them on channel 67
that he had been in collision with a ship called Cypress Pass. He added that he
and his deckhand were not injured; there was little hull damage and no ingress
of water, but there was damage to the mast and aerials. The skipper gave his
position as latitude 54" 56'.25 north and longitude 05’.30 west.
At 0905, Cypress Pass was called by Beverley Ann II on VHF radio channel 16
and was asked to change to channel 11. The skipper told the master that their
two vessels had been in collision and that his fishing vessel had passed down
the port side of the ship. The master and the third officer did not know that the
collision had occurred and asked for the fishing vessel's position. The skipper
gave his position, which was noted by the officers as latitude 56'.58 north
and longitude 01'. 7 west. The master plotted this position on the chart
and, on looking at the radar, could not see any vessel in that position. He did
see an echo entering the Tyne breakwaters and another echo moving in a
southerly direction between Cypress Pass and the coast. The conversation
between the two vessels ended at this point.
Beverley Ann II retrieved her fishing gear and returned to North Shields.
Cypress Pass continued on passage to the anchorage and by 0948 she had been
brought up to her port anchor.
At 1415, the master received a telex from his agent informing him that it had
been reported that his ship had been in collision with a fishing vessel.
1.3.1 Weather
The wind was east-north-east force 4 to 5 with slight seas and a 2-metre swell.
It was overcast and the visibility was between one and two miles, which was
further reduced in squalls.
6
1.3.2 Tidal stream
The skipper/ownerwas 4 1 years old and had been employed in full-time fishing
since 1974. He sailed firstly on cobble boats and then on trawlers. When he
was 20 years old, he bought his first fishing vessel, a trawler, which he sailed
out of North Shields and up to about 100 miles offshore. After four years he
sold his trawler and bought a larger one, which was named Beverley Ann and
which he still owns. He held a Second Hand Special certificate of competency
and in September 1998 he bought BeverIey Ann II.
Given that the radar had only an EBM, was not gyro-stabilised and the fishing
vessel was steering within one point, it would have been difficult to make a
systematic and accurate assessment to determine if the echo was on a steady
bearing. To accurately plot, he would have needed to take a series of ranges,
EBM bearings of the echo and magnetic compass headings. The magnetic
compass headings were graduated at intervals. This information would then
have had to have been plotted on a sheet of paper.
The skipper and his crewman sailed each day from North Shields at about
0600. They trawled for prawns and returned to port at about 1800. The tows
lasted about four hours, and the process of hauling and shooting took about
half-an-hour.
7
Recognising that EPIRBs,liferaftsand float free arrangements are not
mandatory for fishing vessels of less than 12m in length, Merchant Shipping
Notice No M. I467 (issued in September 1991) continues to recommend that
they should be provided in such vessels. The Department of the Environment,
Transport and the Regions (DETR) strongly recommends that all fishing
vessels of less than 12m in length should carry a liferaftfor everyone on board.
The Notice observes that, from experience of casualties to small fishing vessels,
liferafts have been effective in providing essential out-of-water support in a
cold climate.
Beverley Ann II had a 0.5m comer radar reflector, which was mounted aft of
the mast, about 1m above the wheelhouse top and 4.5m above sea level. The
IMO recommends in Resolution A.384(X) I977 that member states should
require vessels of less than l00gt to carry reflectors whose equivalent echoing
area is at least 1Om’, a figure which is given for peak performance. However,
IMO is satisfied with from most directions This requirement is
close to the performance specification of a 0.5mcomer reflector.
e the corner reflector is made of flat metal plates arranged at right angles
to form internal comers. It acts in a similar way to a mirror, and works
most effectively when mounted in the “catch rain” position, in which
none of the points of the triangles is in the vertical;
e the lens reflector consists of a spherical plastic lens which focuses the
incoming radar waves onto a metal coating and reflects them; and
8
The above M Notice states that the orientation of the reflector must follow the
manufacturer’srecommendationsif it is to be effective. In all cases the
reflector should be mounted as high as possible for maximum detection range.
Beverley Ann II had a 0.5m corner reflector which was mounted on the after
side of the mast and about 4.5m above the water level. The orientation of the
reflector meant that its main axis was vertical or “point up”. Manufacturers
recommend that this type of reflector should have its main axis at an angle to
the vertical or in a “catch rain” position.
1.4.5 Damage
There were scrape marks to the GRP and traces of black paint on the port bow
corner. The mast, on top of the wheelhouse, was bent and a number of aerials
had become detached from it (see photographs opposite).
1.5 CYPRESSPASS
1.5.1 The master and crew
The master was 5 1 years old. After attending a nautical college in the
Philippines, he first went to sea in 1974 as a deck cadet, serving on foreign-
going general cargo ships. After obtaining his third officer’s licence, he
changed company and served on bulk carriers. In 1986 he transferred to
another company, serving on bulk carriers and vehicle carriers. He obtained his
master’s licence in 1991 and was promoted to master in 1992, being employed
at this time by a manning agency. He joined Cypress Pass on 12 December
1998 and took command in January 1999, after having undertaken a
familiarisation period. While serving on vehicle carriers, he had visited the
River Tyne on a number of occasions.
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nautical college. During this time he spent one year at sea as a cadet. He
obtained his third officer’s licence in July 1998 and went back to sea on bulk
carriers. He joined Cypress Pass on 18 January 1999.
The ship complied with the conditions of the Liberian Minimum Safe Manning
Certificate.
(‘Note: The management of the ship had been taken over by the Norwegian
company C H Sorensen Management AS on 16 December 1998.)
At the time of the incident, Cypress Pass was on passage from Amsterdam to
the Nissan vehicle discharge berth at Jarrow Slake on the River Tyne. She was
on voyage number 60, which had begun in Japan and continued on to Korea,
Jeddah, Koper and Amsterdam. Once she had discharged the last of her cargo
of vehicles at Jarrow, she was scheduled to begin her return voyage to the Far
East.
The three navigating officers carried out the conventional four-on, eight-off
navigational watches while on passage at sea. The master did not carry out
navigational watches and had had a full night’s sleep on the day of the accident.
The third officer carried out the eight-to-twelve watches and had been off
watch since midnight.
The master was responsible for the overall navigation of the vessel, and the
officer of the watch (OOW) was his representative; responsible for safe
navigation and proper organisation of the navigational watch and available
resources. During heavy traffic, poor visibility, arrival at port or at anchorage
the master was to be on the bridge, while the OOW performed his duties as if
the master was not there. If the master should take over direct command, it
was to be entered in the deck log book and the OOW informed by direct order.
After being relieved by the master, the OOW was to continue to perform his
normal duties and assist the master in navigation.
The document continued with a reference to the ICS Bridge Procedure Guide,
bridge team composition, bridge team duties/functions and style, the deck log
book, orders/information/rules,manual/auto steering change-over, weather
conditions, and the reporting of non-conformities. Under duties and functions,
11
the lookout was never to leave the bridge without permission, and was to be
posted on the bridge wing, not inside the wheelhouse. An annexe was attached
which dealt with attitudes and management skills, communicationsand
briefings, workloads, human involvement in errors with lists of underlying
factors, external errors and internal errors, and judgement and decision making.
The OOW was reminded that the International Regulations for Preventing
Collisions at Sea should be complied with, the engines were at his disposal and
he should not hesitate to use them when necessary. There was a list of the
circumstances in which the master should be immediately notified and of the
OOW’s responsibilities when taking over a watch. The document was signed
by all the serving navigating officers.
The working Admiralty Chart No 152, in use at the time of the incident, was
up-to-date and showed the course line, which was denoted by and the
final waypoint 3 miles off the Tyne breakwaters. In the later stages, during the
approach to the anchorage off the River Tyne, positions were being fixed by
single radar bearings and ranges from points of land.
Doubt existed as to whether the collision had occurred or not, as the officers
on the bridge of Cypress Pass had been unaware of the presence of Beverley
Ann II until they were called after the accident by the fishing vessel on VHF
radio.
The port bow comer of the fishing vessel had been damaged slightly and there
were black marks on it. A small piece of GRP was taken from this area. On 18
May, a representative of the Liberian authorities took paint samples from
various locations on the port side of Cypress Pass (see photograph overleaf).
12
The samples from both vessels were sent to the Forensic Science Services (an
executive agency of the Home Office) for analysis.
The sample from the Beverley Ann II was a small piece of white
fibreglass with a smear of blackpaint on it. Part of this Smeared black
paint was removed and examined microscopically. This showed that it
consisted of a single layer with translucentparticles dispersed
throughout it together with a few orange particles. Thispaint was
indistinguishable microscopicallyfrom the topcoat of the Cypress
Pass.
Cypress Pass was a power-driven vessel underway and making way. Beverley
Ann II was a vessel engaged in fishing and she was restricted in her ability to
manoeuvre because of her extended trawling gear. The fishing vessel was
showing her day signal of two cones with their apexes together. Although it
was daylight she was also showing her navigating lights to indicate that she was
trawling and making way
14
SECTION 2 - ANALYSIS
2.1 RADAR DETECTION OF SMALL CRAFT
Radar reflectors should ideally return radar waves from a perfectly lined-up
metal plate with the all-round consistent performance of a sphere.
A problem in detecting small craft arises with sea clutter, because salt water is
highly reflective to radar waves. In force 6 winds, the theoretical limit of sea
clutter extends to a range of 6 miles on l0cm wavelength (or S band) radars
and 2 miles on 3cm (or X band) radars. There is a control to suppress sea
clutter, and if the gain is turned up too high, smaller/weakerechoes may also be
suppressed and missed. Too little gain and echoes may be lost in the sea
clutter. Only at the correct settings will echoes at close range be detected.
Ideally, an effective radar reflector needs an RCS larger than the boat itself.
However, a large radar reflector on a small boat can create problems because it
can bephysically too large and too heavy, especially if it is mounted high up to
‘see’ over the tops of waves. To give the best performance over the range of
angles and radar frequencies, the geometry of radar reflectors has to be
optimised. This leads to compromise and a reduction in peak performance.
The siting of the corner reflector on Beverley Ann II behind the mast, and not
in the “catch rain” position was not ideal, and increased the likelihood of the
vessel not being detected by Cypress Pass’s radars.
2.2.1 General
Between Cypress Pass’s positions plotted at 0843 and 0900, she covered a
distance over the ground of4.45 miles, which gave a speed of 15.7knots. As
15
Beverley Ann II was making just over 2 knots and the two vessels were nearly
end-on, the closing speed was about 18 knots (see reconstruction overleaf).
Having three DGPS sets to refer to, this position is likely to have been very
accurate and, being stopped in the water, is likely to have been very close to
the position of the collision.
Given the speed of the ship and the above position, the time of the collision has
been calculated as 0854. This is supported by the fact that the skipper called
Tyne Tees Coastguard at 0855, shortly after the collision.
A track line has been drawn through the mean of all the positions plotted
between 0843 and 0930. The above position lies very close to this mean track
line (see extract of Admiralty Chart No 152 above). This indicator, together
with the results of the forensic analysis' of the paint samples taken from both
vessels, leads to the conclusion that the vessels did actually collide.
(* Note: the scientist gave a moderate rating for the proposition that the two
vessels were in collision, because other ships may have the same paint.
However it is highly unlikely that a ship, other than Cypress Pass,was in the
same area of the collision with the same paint.)
The fishing vessel was trawling in restricted visibility, in that she detected the
presence of another vessel by radar before making visual contact. The skipper
had the radar on a 3-mile range.
With a radar range scale of 3 miles and a closing speed with the ship of 18
knots, the skipper had about 10 minutes to determine whether the other vessel
was on collision course and, if so, to decide and take the necessary action to
avoid a close quarter situation. Under Rule 19 of the International
Regulationsfor Preventing Collisions at Sea (collision regulations)the
skipper was obliged to carry out these actions, because the rule applies to all
vessels in restricted visibility, including those engaged in fishing.
The radar was unstabilised and only had an EBM with which to determine
whether an echo was on a steady bearing or not. Rule 7 states that proper use
16
should be made of radar equipment, including long range scanning to obtain
early warning of risk of collision and radar plotting or equivalent systematic
observation of detected objects. By assessing if a vessel is on a collision
course, early and substantial avoiding action can be taken.
The skipper did not take any action, including making sound signals, until he
saw the ship. By this time, Cypress Pass was 0.5 miles away and was bows
onto him,and a very close quarters situation existed. He had less than two
minutes to avoid a collision. He took the correct avoiding action by stopping
his vessel and reversing his engines, as directed by Rule 17(b). This resulted in
a glancing blow on the port bow of the fishing vessel and contact with the mast
as she ran down the side of the ship.
The vehicle carrier was in the process of gradually slowing down for her
approach to the anchorage off the Tyne. There were three people on the
bridge: the master, the third officer and the lookout - all of whom had an
uninterrupted view forward from the bridge because it is not far aft of the bow.
The 3cm and l0cm radars were in operation and were being used by both the
master and the thud officer.
The bridge team was acting in compliance with the basic requirements of its
onboard bridge procedures guides and instructions.
Although the officers had a number of tasks to perform in preparation for the
ship's arrival, when they were monitoring the radars, they did not observe the
echo of the fishing vessel on either of the two radars.
Although it was daylight, visibility was restricted, and they were in busy coastal
waters, so the master kept the lookout posted. The lookout moved from one
bridge wing to the other.
The officers did not make visual contact with the fishing vessel. If they had,
and with a closing speed of about 18 knots and a range ofvisibility of 0.5 mile,
the officers would have had about two minutes in which to determine that a
close quarter situation existed, and then take the necessary avoiding action.
The lookout either did not see the fishing vessel or, if he had, he did not report
it to the officers.
Even when they had become aware of the presence of the fishing vessel after
the collision, they could not see her on the radar screens. An incorrect position
was noted and they would have been looking in the wrong place. However, it
can be assumed that the officers had missed the radar echo of Beverley Ann II
because the radar reflector did not produce a strong enough signal return, due
to its less than ideal siting, or the signals were spurious and they had missed
them, or the radar gain/seaclutter controls were set such that her radar echo
was suppressed.
18
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SECTION 3 CONCLUSIONS
3.1 FINDINGS
4. The two crew members, the skipper and the deckhand of Beverley Ann
II were in the wheelhouse. [1.2]
5. The fishing vessel was equipped with a radar, which was not compass
stabilised and only had an EBM to determine if an echo was
approaching on collision course, and three DGPS sets. [ 1.4.2]
6. The skipper saw a large echo on the edge of the radar screen at 3 miles
but did not assess if it was on a steady bearing. [1.2, 2.2.2]
7. The vehicle carrier was seen at a range of 0.5 miles and was bearing
down on the fishing vessel. [ 1.2]
8. The skipper reversed his two engines but his vessel made contact with
the port shoulder of the ship. [1.2]
9. The fishing vessel sustained damage to her port bow and to her mast;
both were relatively slight. [ 1.4.5]
11. Once his vessel had cleared the ship, the skipper called the coastguard
and then Cypress Pass to inform them of the collision. [ 1.2]
12. Cypress Pass complied with her Liberian Minimum Safe Manning
Certificate. [1.5.1]
13. The bridge of Cypress Pass was manned by the master, the third officer
and a lookout. [ 1.2]
14. The two officers were using a 10cm radar and a 3cm radar; both had
ARPAfacilities. [1.2, 1.5.2]
20
Therefore, they did not detect the presence of the fishing vessel by the two
radars This possibility is a factor to take into account, together with the state
of visibility, in determining a safe speed under Rule 6 of the collision
regulations. Even if Beverley Ann II had been detected, it would have been at
a relatively short range, thereby reducing the time available to make a proper
assessment and take effective avoiding action.
Although a lookout was being maintained, it was not effective in detecting the
presence of Beverley Ann II before the collision, contrary to Rule 5 of the
collision regulations.
If the skipper had taken the wrong avoiding action, (which was possible given
the short time he had to make a decision), his vessel may have been run over by
the ship. If the two crew members had survived the impact and Beverley Ann
II had been destroyed, they would have been left in the sea with only lifebuoys
to keep them afloat. The officers were unaware of the fishing vessel, so the
two fishermen’s predicament was unknown. Their non-arrival back; in port
would probably have been reported to the coastguard later that evening. It is
unlikely that any survivors would be found during the search operation as the
area where the men were fishing was so large. If they had been found after a
long search, it is doubtfulthey would still have been alive.
To enhance their chances of survival after the loss of their fishing vessel, they
would have needed a liferaft. An EPIRB would have alerted the coastguard
that something was amiss, and a search and rescue operation could have been
mounted immediately.
Beverley Ann II had neither items of safety equipment and it was most
fortunate that the contact with the ship only produced minor damage to the
fishing vessel.
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15. The bridge team was acting in compliance with the basic requirements
of its onboard bridge procedures guides and instructions. [2.2.3]
16. The ship was in the process of slowing down gradually from her service
speed of 17.5 knots to her manoeuvring speed in preparation for her
approach to the anchorage off the River Tyne. [1.2]
17. Regular positions were being plotted by the third officer and the master
had the con. [ 1.2]
18. The officers and the lookout did not observe Beverley Ann II by radar
or by sight, either before or after the collision. [ 1.2]
19. The fishing vessel was not equipped with either a liferaft or an EPIRB.
[ 1.4.3]
20. Neither vessel was making sound signals in restricted visibility [2.2.3]
21. The fishing vessel was equipped with a comer type radar reflector but it
was incorrectly mounted to produce maximum radar signal returns.
[1.4.4, 2.1]
3.2 CAUSES
Beverley Ann II
Before he made visual contact with Cypress Pass, the skipper saw a large echo
appear on the edge of the radar screen at 3 miles. He did not however, make a
fill appraisal of the risk of collision and took no avoiding action until the ship
appeared at short range bearing down on him. [2.2.2]
Cypress Pass
The officers and the lookout did not observe the fishing vessel either by radar
or by sight and therefore the bridge team was not keeping a proper lookout.
[2.2.3]
1. Beverley Ann II’s radar had limited facilities with which to assess the
approach of an echo. [1.4.2,2.2.2]
2. Longer range scanning on the fishing vessel’s radar would have given
an earlier warning of the approach of an echo. [2.2.2]
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3. The less than ideal mounting of the radar reflector, and its inherent
problems of efficiently returning radar signals, may not have produced a
consistent echo on the screens of either radar on Cypress Pass.
Alternatively, the officers may have not observed the echo of Beverley
Ann IIby oversight or the sea clutter controls were incorrectly set,
suppressing her echo. [2.1]
4. The lookout may have seen the fishing vessel but did not report her
presence to the officers. [2.2.3]
5. The presence of the fishing vessel may have been brought to the
attention of the lookout if the former had been making sound signals.
[2.2.2]
3.3 OTHERFINDINGS
2. If the fishing vessel had been lost, it is highly likely that the two
fishermen would have lost their lives due to the absence of a liferaft.
[2.3]
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SECTION 4 - RECOMMENDATIONS
Mr Wakenshaw, the owner and skipper of Beverley Ann II, is recommended to:
1. Ensure that the radar reflector on board Beverley Ann II is properly sited and
orientated in accordance with the manufacturer’s recommendations:; and
2. Comply with the collision regulations, by making the appropriate sound signals
and taking the correct action when in restricted visibility.
3. To disseminate the lessons learned from this accident to its personnel in the
fleet; and
23