‘------- -–”~

PB97-916402

NTSB/MAR-97/01/SUM

NATIONAL

TRANSPORTATION

SAFETY

BOARD

WASHINGTON, D.C. 20594

MARINE INCIDENT SUMMARY REPORT

NEAR GROUNDING OF THE LIBERIAN TANK SHIP PATRIOT

BAY OF CAMPECHE, MEXICO

OCTOBER 15, 1995
The National Transportation Safety Board is an independent Federal agency dedicated to

promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety.

Established in 1967, the agency is mandated by Congress through the Independent Safety

Board Act of 1974 to investigate transportation accidents, determine the probable causes of

the accidents, issue safety recommendations, study transportation safety issues, and evaluate

the safety effectiveness of government agencies involved in transportation. The Safety

Board makes public its actions and decisions through accident reports, safety studies, special

investigation reports, safety recommendations, and statistical reviews.

Information about available publications may be obtained by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 L’Enfant Plaza, S.W.

Washington, D.C. 20594

(202)382-6735

(800)877-6799

Safety Board publications may be purchased, by individual copy or by subscription, from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

(703)487-4600
PB97-916402

NTSB/MAR-97/01/SUM

	













MARINE INCIDENT SUMMARY REPORT

Adopted: April 8, 1997

Notation 6825



	




 !"# 	$$%&'

National Transportation Safety Board

Washington, D.C. 20594

MARINE INCIDENT SUMMARY

Vessel: Tank ship Patriot, Liberian registry, LR9006904, 798 feet long,

53,772 gross registered tons, built 1992

Accident Type:

Location:

Date:

Time:

Owner/Operator

Property Damage:

Injuries:

Complement:

Near-grounding incident

Bay of Campeche, Mexico

October 15,1995

Between 0300 and midnight

Conoco Shipping Company, Inc.

Houston, Texas

$100,000 (est.)

None

27 crew

On October 15, 1995, the Liberianregistered motor vessel Patriot, a 95,000

deadweight-ton1 tank ship (see figures 1 and 2),

came within 10 miles (2-3 hours) of grounding

on the north side of the Yucatan Peninsula near

Campeche, Mexico, while navigating in rough

seas and high winds associated with Hurricane

Roxanne. Had the grounding occurred, it could

have resulted in significant damage to the ship’s

structure, injuries or deaths among the 27

crewmembers, and damage to the environment.

The vessel was en route from Galveston, Texas,

to Dos Bocas, Mexico, when the near-grounding

incident occurred.

In its investigation, the Safety Board

identified the following safety issues: the

master’s decisionmaking, Conoco Shipping

Company’s monitoring of weather and its

management of the movement of its vessels, and

Conoco Shipping Company’s shoreside support

for shipboard decisionmaking. The following

discussion includes a narrative description of

the incident and the events leading to it, a

consideration of the safety issues and their

relationship to this incident, a list of conclusions

drawn from the investigation of the incident,

and a set of safety recommendations developed

to help prevent a recurrence of incidents of this

type.

1

Deadweight tons refers to the total weight of cargo,

fuel, and stores a ship can carry, measured in long tons

(2,240 pounds).

3
BACKGROUND OF INVESTIGATION

Because the near-grounding incident

involving the Patriot occurred in international

waters and did not involve a vessel of U.S.

registry, the National Transportation Safety

Board did not have jurisdiction to investigate,

find probable cause, or make safety recommendations concerning the incident. However,

Conoco Shipping Company, Inc., owner of the

Patriot, was concerned about the potential

damage to the company’s ship, injuries to its

crew, and damage to the environment that could

have resulted from the Patriot’s encounter with

Hurricane Roxanne. In the interest of preventing

similar incidents in the future, and recognizing

the benefits of an independent review of the

circumstances surrounding the near grounding

of the Patriot, the company asked the Safety

Board to undertake an investigation to

determine the probable cause of the incident.

The Safety Board, believing that investigations

of incidents as well as accidents can yield

significant safety lessons, determined that it

would be in the interest of transportation safety

to conduct an independent, public inquiry into

the circumstances that led to this incident.

The Safety Board looked at both the

shipboard and shoreside aspects of the incident.

Conoco personnel were frank and honest in their

response to the investigation and did not

withhold any information that was requested of

them. Moreover, Conoco management agreed

with the Safety Board stipulation that no

adverse action would be taken against any

employee whose role in the incident might be

questioned because of the Safety Board’s

scrutiny. The Safety Board commends Conoco

Shipping Company for its willingness to invite

scrutiny of its policies and procedures in the

interest of transportation safety.

6

Yucatan Peninsula’s east coast. At 2100 on

October 10, Roxanne, now classified as a

hurricane, made landfall about 100 miles south

of Cancun, Mexico. (See figure 4.) During the

next 9 hours, the storm moved in a westerly

direction across the Yucatan Peninsula toward

Dos Bocas at a speed of about 10 knots.

At 0853 on October 11, the agent 4 at Dos

Bocas sent telexes to Conoco Shipping

Company’s main office in Houston and to the

master of the Patriot, informing them that the

port was closed because of gale-force winds5

from Roxanne and that weather forecasts were

predicting even stronger winds later that day.

The message to company headquarters was

received by the company’s vessel coordinator,

who passed it on to his supervisor, the director

of chartering and traffic. The director of

chartering and traffic passed the information to

members of the company’s tanker operations

optimization team (TOOT).6 The company took

no further action. The message to the master

asked that he provide the agent with the vessel’s

position, as well as his intentions. After

checking the latest NWS forecasts, the master

notified the agent that he intended to continue

the voyage to Dos Bocas. (See figure 5.)

At 1500 on October 11, the Patriot arrived

at the anchorage for the Dos Bocas single point

mooring (SPM) facility located about 17 miles

offshore, and the master tendered the vessel’s

notice of readiness (NOR).7 The master said

that, because of deteriorating weather and sea

conditions, he chose not to anchor but to remain

4

Local agency representing the interests of Conoco

and the charterer in the Port of Dos Bocas. The agent also

acts as liaison between Conoco and local port authorities

regarding such activities as the purchase of stores and

bunkers, the transport of relief crews, and the

loading/discharge of cargo.

5

Winds in excess of 34 knots.

6

TOOT comprised a group of senior members of

Conoco management who oversaw day-to-day operation of

the company’s tank ship fleet. Shoreside team members

included the marine superintendent, the engineering

superintendent, the director of chartering and traffic, and

the vessel coordinator.

7

An NOR, tendered to officials at a loading/discharge

port, signifies that a vessel has arrived and is ready, in all

respects, to load or discharge cargo

under way in the vicinity of Dos Bocas until

weather and sea conditions improved. Between

1500 and 2000, sea condition’s deteriorated

sharply as Roxanne approached Dos Bocas. By

2030, the wind had increased to more than 100

knots, with the vessel rolling and pitching

heavily in 20-to 30-foot seas.

At 0348 on October 12, the pitching and

rolling of the Patriot became so severe that the

vessel’s main engine went into an overspeed

condition and shut downs The engine was

restarted and manually throttled down to slow

ahead (50 rpm). According to the chief

engineer, this speed reduction was necessary to

reduce the probability that the main engine

would again overspeed and shut down. Conoco

management later informed the Safety Board

that both the Patriot and its sister ship, the

Guardian, had previously experienced main

engine overspeed while operating in a light

ballast condition in rough seas. The master and

chief engineer on board the Patriot on October

12, 1995, were not on board the vessel during

the past overspeed occurrences, and they stated

that they had not been alerted to the problem

before this incident.

The master was aware that one alternative

for dealing with the overspeed condition was to

load storm ballast into one or more of the

vessel’s cargo tanks.9 Additional ballast would

increase the vessel’s draft and reduce the

magnitude of rolling and pitching, thereby

allowing engine rpm to be increased without

creating an overspeed condition. (See figure 6.)

At 0715 on October 12, the master ordered his

8

The main engine and direct-connected propeller shaft

on the Patriot were programmed to automatically shut

down if the shaft exceeded about 115 rpm. Normally, a

governor regulates the main engine/propeller shaft speed

and prevents overspeeding. In this case, however, the

vessel’s pitching motion brought the Patriot’s propeller

blades very close to the surface, thus reducing water

resistance and resulting in a shaft acceleration that the

governor could not correct in time to prevent engine

shutdown.

9

Storm ballast is saltwater ballast taken aboard to

improve a vessel’s seakeeping in rough seas. This ballast is

in addition to the saltwater ballast the vessel normally

carries.
——. — _____ .- - —— — .—

@ Hurricane

1 Tropical Storm

------4 .C:f’’rl, --L---L

1

I~ v. ..-&..

)

.——

Figure 4- Approximate track of Hurricane Roxanne October 10-16,1995
7--T-”-”--”-‘--i--”--+-t-------l----’”

Ioc;::rloy

24°

23°

L.,:,

‘\~.

.,., .-

. . . :.

. . . . i 070c:%F

I I /1 ‘ a.---..-

W7W WI I I

r

. .

SPM

“

. .

i f

A 95W 94° 93° -

92° 9i “ 90’W 8;0 88°

- ‘ON

19°

18°

Figure 5- Relative positions of Patriot and Hurricane Roxanne when hurricane made landfall (2100 on October 10) and when

Patriot’s master made the decision to continue voyage toward Dos Bocas (0900 October 11)
9

Figure 6- Approximate draft of Patriot-class tank ships when operating in light ballast condition (top) and

when fully loaded (bottom)

chief officer to commence the loading of

saltwater ballast into the No. 4 cargo oil tank.

Between 0900 and 1130, weather and sea

conditions improved as Roxanne, now located

about 60 miles north of the Patriot, wa s

downgraded to a tropical storm. Shortly after

the Patriot completed the loading of saltwater

ballast (13 15), port authorities announced that

the Port of Dos Bocas would soon reopen, To

prepare for loading cargo, the master moved the

Patriot offshore at about 1915 and began

discharging storm ballast from the No. 4 cargo

tank.10

Roxanne continued on a west-northwest

heading through the evening of October 12. The

0300 October 13 NWS forecast showed the

storm turning northward and weakening as it

moved slowly offshore. By 1500 on October 13,

the storm had moved more than 180 miles north

and west of Dos Bocas and had been

downgraded to a tropical storm. The NWS

forecasts received during the morning of

October 14, however, showed the storm

regaining intensity. The 1200 and 1500 NWS

forecasts on October 14 reported that Roxanne

had regained hurricane strength, had turned, and

was moving in an east-southeast direction

toward Cayo Arcas. 11

10The discharge of storm ballast was completed at

0200 on October 13.

11Cayo Arcas is an offshore oil production platform 

About 1700 on October 14, the Conoco

engineering superintendent telephoned the

master of the Patriot; he stated that his decision

to call was prompted by an earlier conversation

he had with the master of the Pioneer. 12 The

engineering superintendent and the master of

the Patriot discussed the vessel’s position in

relation to Roxanne, on-scene weather and sea

conditions, and whether storm ballast should be

loaded into the No. 4 cargo oil tank. They did

not discuss the overspeed problems experienced

earlier in the voyage. According to the

engineering superintendent, he was not

concerned about the vessel’s safety at that time

because the master had told him “not to worry,

that the vessel was handling the situation all

right.”

The Incident

By 0300 on October 15, the eye of

Hurricane Roxanne had moved southeasterly to

within 85 miles of the Patriot. At this point,

located 100 miles northeast of Dos Bocas.

12The Pioneer was a sister vessel to the Patriot en route

(in ballast) to Cayo Arcas, where it was to load a cargo of

crude oil. According to the master of the Pioneer, his vessel

had approached to within 55 miles of Cayo Arcas when it

received the October 14 NWS forecasts (1200 and 1500)

indicating that Roxanne had turned and was heading toward

Cayo Arcas. Shortly after receiving the 1200 NWS forecast,

the Pioneer turned onto a northeasterly direction and

departed the area. At the time of the telephone call with

Houston, the Pioneer was more than 175 miles north of the

storm.
10

because the Patriot was essentially hemmed in

between the storm and the shore with no easy

avenue of escape (see figures 7 and 8), the

master turned the vessel into the wind and

waited for conditions to improve. During the

early morning of October 15, watchstanders

reported winds in excess of 130 knots and rough

seas that caused the vessel to roll and pitch

heavily. At 0421, the main engine once again

went into an overspeed condition and shut

down. Although the engine was quickly

restarted, engine speed had to be limited to

about 50 rpm.

About 0600, the master telephoned the

engineering superintendent at. home and

reported that he was having difficulty maneuvering his vessel. The engineering

superintendent reported this “urgent matter” to

his superiors. Meanwhile, the vessel’s inability

to move out of the storm’s path and its

proximity to land and nearby hazards to safe

navigation prompted the master (at 0611 ) to

order the second officer to transmit a series of

distress messages via the vessel’s INMARSAT

A, INMARSAT C,13 and VHF-FM radiotelephone. The distress calls were routed to the U.S.

Coast Guard in New Orleans and to Conoco

Shipping Company in Houston. The second

officer also made calls for assistance to nearby

vessels and to the Mexican Government. No

immediate assistance was available because of

the severity of the on-scene weather and sea

conditions.

While the second officer was transmitting

distress messages, the master ordered the chief

officer to assemble all available crewmembers

outside the radio room, where they were

updated on the situation. At 0637, the master

ordered his chief officer to once again begin

loading saltwater ballast into the vessel’s

forepeak, afterpeak, and No. 4 cargo tanks.

131NM4RSAT A is the original INMARSAT (satellitebased) communications system, which has been in operation

since 1982. The system is based on analog techniques and is

capable of global two-way voice-grade telephony (and voiceband data transfer), facsimile, and telex communications.

INM4RSAT C is a digital satellite communications system,

operating since 1991, that provides two-way store-andforward messaging and distress alerting capability.

Later, the master decided to load additional

saltwater ballast into the No. 7 port and

starboard slop tanks. 14

Deteriorating weather and sea conditions

hampered efforts to load the storm ballast from

the outset. According to the chief engineer, the

rolling movement of the Patriot repeatedly

activated the auxiliary steam boilers’ low-water

trip switches, resulting in the periodic shutdown

of the vessel’s two auxiliary boilers, which

supplied steam to power the ballast pump.

Global Positioning System (GPS) fixes

taken between 0600 and 0830 showed the

Patriot being set by the wind and sea in a

northeasterly direction toward shoals about 23

miles away. The waters in this area were littered

with oil rigs and numerous uncharted hazards to

safe navigation, such as underwater well-heads

and pipelines. About 1030, the helmsman

reported that the vessel was no longer

responding to the rudder. Shortly thereafter

(1043), the master participated in a conference

call with senior Conoco Shipping Company

management in Houston (the company

president, the marine superintendent, the

engineering superintendent, the manager of

operations and engineering, the fleet safety

officer, and others) and apprised them of the

circumstances facing the Patriot, which at that

time was about 15 miles west of the shoals off

Campeche15 and 40 miles from the eye of the

storm.

Shortly after 1300, on-scene weather and

sea conditions improved as the Patriot, now less

than 10 miles west of the shoals off Campeche,

entered the eye of Hurricane Roxanne. For the

next 6 hours, the vessel reported light winds out

of the south-southwest at 4 to 6 knots. The chief

officer used this time to complete the loading of

ballast. Almost as soon as the loading of the

additional ballast was completed (1900), the

Patriot passed through the wall of the eye,

14Slop tanks are used to store oily residue resulting from

the cleaning of cargo tanks.

15 Campeche is located about 275 miles northeast of Dos

Bocas, The city has no deepwater harbor. In addition, shoals

located north and south of this city extend more than 45

miles into the Gulf of Mexico.
94”1 93+ 92” 91 “1

I

Figure 7- Relative positions of Patriot and HurricaneRoxanne during the tank ship’s most serious encounter with the storm


14

entered the storm’s navigable semicircle,16 and

encountered rough seas and winds reportedly in

excess of 130 knots. The additional ballast

improved the Patriot’s ability to maneuver by

increasing the vessel’s draft and thus permitting

increased main engine rpm. The chief engineer

was able to increase rpm from slow ahead to

half ahead (70 rpm), providing the vessel with

enough speed to move in a northerly direction

away from the storm. By midnight on October

15, the Patriot, though continuing to encounter

hurricane-force winds and rough seas, was able

to move about 50 miles offshore and away from

the nearest shoals.

Over the next 12 hours, the master of the

Patriot continued to maneuver the vessel

offshore and away from Roxanne. By noon on

October 16, the vessel had cleared the shoals

north and east of Cayo Arcas and was able to

head for open sea. By 2100, the NWS reported

Roxanne had again been downgraded to a

tropical storm. By 1100 the next morning

(October 17), the storm was downgraded to a

tropical depression.

Post-incident Events

Following its encounter with Hurricane

Roxanne, the Patriot proceeded to Galveston.

While en route, the crew conducted a deck and

engineering darnage survey. The survey

revealed no structural damage to the Patriot, but

an inspection of the No. 4 cargo tank showed

that the movement of saltwater ballast within

the tank during the emergency had ripped the

heating coils and hydraulic lines free of their

fasteners, rendering them unusable. The damage

to the hydraulic lines, which controlled the

opening/closing of the ballast/cargo valves in

the No. 1 and No. 4 cargo tanks and the No. 7

port and starboard slop tanks, was so severe that

16In the northern hemisphere, the dangerous semicircle

is that half of a storm lying to the right of the storm’s track. It

is within this area that mariners can expect to encounter the

strongest winds, the heaviest rain, and the highest seas. The

navigable semicircle is that half of a cyclone lying to the left

of its track where weather and sea conditions are less severe,

allowing vessels an opportunity to move more easily away

from the storm.

the cargo and ballast valves in these tanks were

no longer operable.

Conoco Operations

At the time of this incident, Conoco

operated a fleet of 8 tank ships, 7 towboats, and

17 barges engaging in international, coastwise,

and inland trades. The company’s four Patriotclass tank ships operated almost exclusively in

the Gulf of Mexico, the East/West Caribbean,

and along the U.S. East and Gulf Coasts. None

of the vessels were equipped with voyage event

recorders.

Organizational Structure -- At the time of this

incident, the three main operating units of

Conoco Shipping Company were the Domestic

Marine Department, the Chartering and Traffic

Department, and the Operations and

Engineering Department, all answering to the

manager of marine, who was a licensed master

with commercial experience and ship operations

expertise. (See figure 9.) The manager of marine

also served as president of Conoco Shipping

Company.

The Domestic Marine Department was

responsible for the day-to-day operation and

oversight of Conoco’s fleet of tugboats and

barges operating primarily in the inland and

western rivers trade.

The Chartering and Traffic Department was

responsible for chartering and scheduling ships,

arranging cargoes for the entire Conoco fleet,

and all other matters related to charter

agreements. Most of the day-to-day activities of

this department were the responsibility of the

director of chartering and traffic and the vessel

coordinator.

The Operations and Engineering Department was responsible for the maintenance and

repair, stores, and staffing of the company’s

eight tank ships. The department was also

responsible for maintaining, updating, and

implementing the policy guidance contained in

the company’s Dec/Engine Procedures

Manual; Navigation, Safety and Bridge

Management Manual; and Vessel Response

Plan. The Operations and Engineering
15

Manager of Marine

(President, Conoco

Shipping Company, Inc.)

Marine Vessel

‘h

Vessel

Superintendent Master Coordinator

Figure 9-- Selected organizational elements of Conoco Shipping Company, Inc.

Department staff included several licensed

masters and chief engineers, including the

marine superintendent during this incident, who

had extensive experience and expertise in

operating crude oil tank ships.

Day-to-day oversight of all company tank

ships was the responsibility of the company’s

two engineering superintendents. According to

these two individuals consulted on

voyage maintenance and repair issues,

supervised shipyard repairs, and prepared

requisitions and work orders for materials or

technical services. They were also responsible

for developing relationships with key equipment

and technical services suppliers. The

engineering superintendent assigned to oversee

the day-to-day activities of the Patriot before

the incident was a licensed chief engineer.

Master's Qualifications - The master of the

Patriot during this incident was fully licensed

and met all international standards and

requirements for shipmasters. He had more than

15 years’ experience as a ship’s officer and had

served as master on Patriot-class vessels for

about 1 year prior to this incident.

SAFETY ISSUES

The first in the sequence of events leading

to the near grounding of the Patriot occurred on

October 11, 1995, when the Patriot’s master

decided to sail his vessel into an area where

NWS forecasts showed he would probably

encounter Hurricane Roxanne. Despite the

weather predictions, the master chose to

maneuver his vessel toward the hurricane rather

than away from it. This decision ultimately

placed the Patriot in the eye of the storm.

In its investigation of this incident, the

Safety Board attempted to determine why a

qualified and experienced seaman such as the

master of the Patriot would take such a course

of action. A review of the activities of Conoco

Shipping Company shoreside managers

preceding and during this incident suggests that

the questionable decision by the Patriot’s

master and the subsequent difficulties

experienced by the Patriot in its encounter with

Hurricane Roxanne could have been avoided.

The following major safety issues were

identified during this investigation:
16

● The master’s decisionmaking;

● Conoco Shipping Company’s

monitoring of weather and its

management of the movement of its

vessels; and

● Conoco Shipping Company’s

shoreside support for shipboard

decisionmaking.

The Master’s Decision

In the view of the Safety Board, the master

of the Patriot demonstrated poor judgment

when he directed his vessel into an area directly

threatened by a hurricane. When investigators

asked the master why he decided to continue

toward, rather than away from, Dos Bocas when

he knew a hurricane was approaching the area,

he said he based his decision on the following

factors:

. His expectation that Roxanne would

alter course toward the northwest

because of the tendency of hurricanes in the northern hemisphere to

follow a northwesterly track;

. His concern that if the storm

continued on its westerly track, the

Patriot could be caught in the

storm’s dangerous semicircle;

. His belief that, even if the storm

continued on its predicted track, the

Patriot had sufficient power to

avoid it; and

. His concern that failing to tender an

NOR before midnight on October

11 (as required by the charter

agreement) would make Conoco liable for substantial additional

operating expenses and could affect

his annual performance evaluation. 17

17The contract stipulated that, should the vessel not

tender the NOR on time, the cost of operating the vessel

would be shouldered by Conoco Shipping Company.

While the charter agreement specified a demurrage rate of

$19,000 per day, the master of the Patriot stated that the

Patriot costs approximately $32,000 per day to operate.

According to Conoco officials, the contract did not state who

The Safety Board examined these and other

factors that influenced the master’s decision to

proceed to Dos Bocas, as well as subsequent

decisions he made during the near-grounding

incident.

Monitoring and Management of Weather-Related

Activities -- A copy of the weather forecasts

received and plotted by the Patriot’s master

between 0900 on October 10 and 1200 on

October 11 clearly showed Roxanne heading in

a west-southwest direction toward Dos Bocas at

a speed of about 10 knots. Neither weather

reports nor forecasts indicated the storm was

about to turn and head in a northwesterly

direction when the master made his decision to

continue southward toward Dos Bocas. By the

time the Patriot arrived at the Dos Bocas

anchorage and tendered its NOR (1500 on

October 11), the eye of the storm was less than

160 miles away.

Because the effects of Roxanne were felt

over such a large area (estimated at more than

150 miles from the eye), the Patriot would

probably have encountered the brunt of the

storm regardless of whether Roxanne veered

toward the northwest as the master anticipated.

As the circumstances later showed, the weather

forecasts received by the Patriot between

October 9 and 12 were accurate. Roxanne did,

as forecast, follow a west-southwest track

toward Dos By the time it became

evident to the master that Roxanne was not

going to turn toward the northwest, it was

already too late for him to do anything but

remain near Dos Bocas and ride out the storm as

best he could.

This incident demonstrates the potential

problems associated with relying primarily on

shipmasters to evaluate the risks posed by

tropical cyclones and hurricanes. The Safety

Board is concerned that the Patriot’s master

would even contemplate operating the Patriot

near a tropical storm, let alone a hurricane,

when it could have been avoided. Had a

grounding incident actually occurred, the

would have paid the Patriot’s operating expenses had the

vessel been delayed in tendering its NOR because of

deteriorating weather and sea conditions en route.
17

damage to the ship’s structure, salvage

expenses, lost revenue, and costs associated

with the clean-up of any resulting pollution (the

Patriot was carrying more than 120,000 gallons

of diesel fuel and lubricating oil) could have run

into the millions of dollars.

In the view of the Safety Board, the failure

of Conoco to anticipate the weather-related

problems facing the Patriot and to initiate

communications with the ship’s master before

the vessel became engaged with the storm

suggests that, at the time of this incident,

company oversight of the activities of its

Patriot-class tank ships operating near tropical

storms and hurricanes was deficient. When

 officials were asked where company

managers obtained weather information during

this incident, they stated that the information

came from calling the NWS or from watching

The Weather Channel on television,

When the vessel coordinator was notified on

October 11 that the Port of Dos Bocas was

closed because of high winds, he notified his

supervisor, who notified the tanker operations

optimization team, but no one took any action

with respect to the Patriot, which was known to

be sailing toward the port. The marine

superintendent said he did not become

personally involved with the Patriot until the

manager of marine called him and other

personnel to ask that they report to the office “to

monitor the situation and assist the vessel as

necessary.” This was October 15, several days

after the Patriot’s initial encounter with

Roxanne. The Safety Board concludes that

Conoco Shipping Company, at the time of this

incident, did not have in place a shoreside

multidisciplinary team specifically responsible

for assisting and advising the company’s

masters in assessing and responding to the risks

posed by tropical storms and hurricanes.

Conoco Shipping Company’s practices

related to weather monitoring and vessel

oversight are of particular concern to the Safety

Board, given the frequency with which tropical

cyclones pass through the company’s operating

area and the risks those storms pose to the safety

and well-being of the company’s vessels and

crews. According to the NWS, more than 900

tropical cyclones were reported in the North

Atlantic between 1886 and 1992. A large

percentage of these storms followed a track into

the East/West Caribbean, the Gulf of Mexico,

and the U.S. East and Gulf Coasts, where

Conoco’s Patriot-class tank ships operate. In

1995 alone, 19 tropical cyclones were reported

in this area, 3 of which (Tropical Storm

Gabrielle and Hurricanes Opal and Roxanne)

passed through the Bay of Campeche. At least

three tropical cyclones and hurricanes passed

through the Bay of Campeche during the 1996

hurricane season.

The Safety Board commends Conoco for the

actions the company has taken since this incident to provide for more effective weather

monitoring. According to Conoco officials,

various operations and commercial personnel

now monitor weather, and the vessel

coordinator sends weather updates to a vessel

whenever a storm is in proximity to it. The

marine superintendent said that he now becomes

involved whenever a tropical depression, storm,

or hurricane threatens a company vessel to

ensure that communications are being

exchanged between the vessel and the vessel

coordinator. He said the vessel coordinator is to

advise operations personnel (the marine

superintendent or engineering superintendent)

whenever their support is required. These

actions demonstrate that Conoco Shipping

Company is aware of the need for more

effective oversight of vessels threatened by

hazardous weather and sea conditions.

To further improve the effectiveness of

company oversight over day-to-day operations

and to ensure a more cooperative approach to

evaluating weather-related risks to vessel safety,

the Safety Board believes Conoco Shipping

Company should develop and implement a

heavy weather operations contingency plan

similar to its Vessel Response Plan that is

capable of providing a timely assessment of the

risks to vessels in the fleet operating near

tropical storms and hurricanes. The plan should,

at a minimum, (1) establish a shoreside response

team that includes individuals knowledgeable in

meteorology and in all engineering, operational,
18

and commercial factors that affect the safety of

vessels in the Conoco fleet; (2) outline the

duties and responsibilities of the response team;

and (3) provide procedures to facilitate

coordination and consultation between response

team members on shore a n d Conoco

shipmasters at sea.

Vessel Maneuverability -- The master stated that

he believed the Patriot had sufficient

maneuverability to evade the storm, whether or

not it veered to the northwest as he anticipated.

He was clearly overestimating his vessel’s

ability to maneuver in rough seas while

operating in a light ballast condition. Patriotclass tank ships carry a minimum amount of

ballast; thus they tend to roll and pitch heavily

in rough seas. Further, few tank ships operating

in a light ballast condition in heavy weather and

rough seas can be operated safely at their full

sea speed. These factors alone make it unlikely

that the Patriot, without the benefit of a

substantial head start, could have outrun the

fast-moving Roxanne.

The Patriot’s ability to maneuver through

rough seas was further compromised by the

unexpected (by the master and chief engineer)

incidents of engine overspeed and shutdown the

vessel experienced. Following each overspeed

incident, shaft speed had to be limited to about

50 rpm, which had a continuous impact on

maneuverability. This impact was particularly

evident on October 15, when the Patriot was not

only unable to maneuver away from the storm,

but also was no longer able to maneuver within

it, as evidenced by the loss of steerage during

the morning and early afternoon of October 15.

As weather and sea conditions deteriorated

during that time, onshore winds began setting

the Patriot in a southeasterly direction toward

land. Only after the vessel entered the eye of the

storm and the loading of storm ballast was

completed were engineers able to increase

engine rpm sufficiently to allow the ship to

move toward the north and away from the

storm.

A review of Conoco records revealed that

two of its four Patriot-class tank ships (Patriot

and Guardian) had experienced overspeeding of

the main engine on three occasions prior to the

near-grounding incident. On two of the three

occasions, the overspeed condition occurred

while the vessels, in a light ballast condition,

were encountering 22- to 33-knot winds and 5-

to 10-foot seas. The third overspeed incident

occurred aboard the Guardian just 6 months

prior to this incident, while the vessel was

operating in a light ballast condition in heavy

weather and rough seas off the U.S. East Coast.

On September 28, 1992, Conoco sent an

urgent message to the shipbuilder and to the

manufacturer of the engine governor and its

regulating linkage seeking their assistance in

resolving the overspeed problem (the two

vessels were still under warranty at the time).

Shortly thereafter, service representatives from

the shipyard and from the manufacturer of the

governor and regulating linkage arrived and

inspected the governor controls aboard both

vessels, According to Conoco, the shipbuilder

and engine manufacturer reported that the governors aboard both the Patriot and the Guardian

performed according to specifications. They

also reported that main engine overspeeds due

to heavy weather and rough sea conditions

could be avoided if the main engine speed were

reduced by 7 percent. Conoco subsequently

informed its chief engineers of this operational

limitation, but the company did not ensure that

masters and chief engineers who joined the

company or began to work aboard Patriot-class

vessels subsequent to this period (such as the

master and chief engineer in this incident) were

informed of the tendency for Patriot-class tank

ships to experience an overspeed condition.

The fact that overspeeding had occurred on

Patriot-class tank ships was information needed

by the masters and chief engineers of all the

company’s Patriot-class vessels so they could

factor it into their risk assessments. In this

instance, the Patriot’s master and chief engineer

lacked critical information concerning the

operation of their vessel in rough seas. Because

neither individual was aware of the overspeed

problem, they were unable to adequately assess

its effect on the Patriot’s ability to maneuver in

rough seas. This information would certainly

have been a factor in the decision to continue
19

the voyage to Dos Bocas. The Safety Board

therefore believes that Conoco Shipping

Company should amend its Deck/Engine

Procedures Manual and Fleet Procedures Guide

to ensure that shipmasters and chief engineers

assigned to Patriot-class tank ships are aware of

the potential for an engine overspeed condition,

the circumstances under which this condition

can occur, and its effect on vessel

maneuverability. The company should also

provide the deck and engineering officers

aboard these vessels with specific guidance

concerning the actions to be taken to prevent a

main engine overspeed condition from

developing.

While the Patriot’s master was not aware of

the potential for engine shutdown in rough seas,

he also did not take into account other

operational limitations of Patriot-class tank

ships. For example, the master understood that

taking on storm ballast would improve the

vessel’s seakeeping in rough seas. But he

apparently did not factor into his

decisionmaking either the time it takes to

complete the loading of ballast or the fact that

exaggerated rolling of the vessel could shut

down the auxiliary boilers that supply the steam

necessary to drive the ballast pumps, thereby

making the ballasting even more difficult and

time-consuming. Had the master taken either of

these factors into account, he might not have

made the decision to continue to Dos Bocas, and

he almost certainly would not have delayed his

decision to load storm ballast for the second

time. The Safety Board concludes that, had the

Patriot’s master better understood the

operational limitations of his vessel, had he

known the vessel could enter an overspeed

condition, and had he considered the effects

rough seas could have on his vessel’s ability to

load storm ballast, he probably would not have

entered the Bay of Campeche, much less

continued the voyage to Dos Bocas. The Safety

Board therefore believes that Conoco Shipping

Company should conduct an engineering and

operational analysis of the performance of its

Patriot-class tank ships when operating in a light

ballast condition in heavy weather and rough

seas with the objective of determining the

operational actions that should be taken to

ensure the safety of those vessels under such

conditions. The company should then provide

the masters, deck officers, chief engineers, and

engineering officers assigned to these tank ships

with the training and guidance necessary to

ensure that they fully understand the operational

characteristics, capabilities, and limitations of

Patriot-class vessels and are aware of the actions

that must be taken to ensure the safety of those

vessels when operating in rough seas.

Satisfying the Charter Agreement -- The master’s

desire to satisfy the terms of the charter

agreement was another factor affecting his

decision to continue the voyage to Dos Bocas.

Under the terms of its contract, the Patriot was

required to arrive in Dos Bocas and tender its

NOR to the local cargo agent before midnight

on October 11. The master expressed his

concern that the expenses incurred as a result of

his inability to tender the NOR on time could

affect his job performance evaluation.18

Conoco’s Navigation Safety and Bridge

Management Manual contains numerous

references to the master’s prerogative to take

any action in the interest of preserving the

safety of the Patriot and its crew. For example,

company guidance states that the master:

is to observe weather conditions

closely at all times and he is not

to hesitate to alter course,

reduce speed, or put into port to

avoid weather that may be

hazardous to the vessel or

endanger those aboard.

Despite this general guidance, the terms of

the charter agreements and masters’ perceptions

of the criteria used by the company to evaluate

their job performance can motivate masters to

take undue risks in order to stay on schedule. In

the view of the Safety Board, the Patriot’s

master should have been provided with

company guidance specifically permitting him

18Documentation provided by Conoco indicates that,

of the factors making up the final performance appraisals

for company masters, 50 percent are safety-related; 25

percent rate leadership skills; and 25 percent reflect other

performance criteria.
20

to postpone the tendering of the NOR on

account of poor weather and sea conditions.

More significantly, had procedures been in

place to facilitate his speaking to Conoco

management about Roxanne and its potential

effect on his ability to fulfill the terms of his

charter agreement, the decision to continue the

voyage to Dos Bocas, as well as the difficulties

encountered by the Patriot resulting from that

decision, could have been avoided.

Ballast Operations -- The delay in loading

storm ballast during the Patriot’s second

encounter with Roxanne had serious safety

implications. Because of the reduced engine

speed, rough seas, deep swells, and hurricaneforce winds out of the west-northwest, the

Patriot soon lost steerageway, began to drift

toward nearby shoals, and began to experience

heavy rolling. At one point, the vessel

reportedly rolled more than 39 degrees. 19 By

0615, the master had become sufficiently

concerned about the situation that he ordered the

second officer to transmit a series of distress

messages. Despite the master’s concern about

the danger of grounding, he did not initiate the

loading of storm ballast until several hours after

the recurrence of the overspeed condition and

more than 13 hours after receiving word that

Roxanne had turned around and was heading in

his direction.

This delay greatly hampered the master’s

efforts to maneuver his vessel in the rough sea

conditions. Moreover, the increased rolling

experienced by the Patriot during the morning

of October 15 caused the thousands of tons of

ballast already in the No. 4 cargo oil tank to

move around, extensively damaging the tank’s

heating coils and hydraulic lines; it also caused

the vessel’s two auxiliary boilers to shut down

repeatedly. The damage to the heating coils and

hydraulic lines did not have an immediate

impact on operations, but the shutdown of the

auxiliary boilers seriously hampered efforts to

complete the loading of storm ballast.

19The maximum reading on the vessel’s inclinometer

was 39 degrees.

The engineering superintendent assigned to

monitor the Patriot-class tank ship fleet stated

that he spoke with the Patriot’s master twice

prior to the vessel’s second encounter with the

storm. But the engineering superintendent was

not experienced in shiphandling, stability, or

meteorology and thus was unable on either

occasion to provide effective decisionmaking

assistance to the master. While the two men

talked about the possibility of loading storm

ballast, the decision whether to load the

additional ballast was left to the master, who

said that at the time the vessel was operating

“all right.” The master did not discuss with the

engineering superintendent the vessel’s previous

difficulties, nor did they discuss the conditions

the vessel would likely encounter or the actions

that should be taken should Roxanne continue

on its predicted path toward the Patriot.

The Safety Board concludes that if Conoco

employees and managers having both operations

and engineering experience had been in contact

with the Patriot’s master during the critical

period leading up to the vessel’s second and

more serious encounter with the storm, these

individuals could have assisted the master with

his decisionmaking. This assistance could have

included advice about the benefits of loading

storm ballast in a timely manner as a means of

avoiding/mitigating an emergency situation.

Shoreside Participation in and Support

of 

The circumstances of this incident indicate

that Conoco should take a more active role in

evaluating and responding to the risks to its fleet

posed by tropical storms and hurricanes. For

example, had Conoco management identified

the risks to vessel safety posed by Roxanne and

had management discussed the situation with

the Patriot’s master during his initial approach

to Dos Bocas, a more informed discussion of the

course of the storm, its effect on the Patriot, and

alternative courses of action would probably

have occurred.

Active decisionmaking support prior to the

vessel’s second encounter with the storm would

have been particularly meaningful given the
21

conditions under which the master and his crew

were working during the emergency. All

crewmembers interviewed said that their normal

routines were interrupted as a result of

deteriorating weather conditions beginning at or

about 1600 on Wednesday, October 11. The

master essentially remained awake for the next

16 hours, until the morning of Thursday,

October 12. Additionally, he stated that about 2

days later, he remained awake and on the bridge

for approximately 48 hours straight, during

which time he napped for intervals of between

20 and 30 minutes. The Safety Board therefore

concludes that the likely fatigue of the master as

a result of his lack of rest during the protracted

emergency may well have compromised his

ability to make good and timely decisions.

Under these conditions, assistance from wellrested shoreside experts would have been

particularly appropriate.

The Patriot’s master did participate in a

conference call with top Conoco Shipping

Company officials on October 15. But by then,

the vessel was already enduring the brunt of the

storm, and the company officials could do little

more than offer encouragement. The Safety

Board concludes that, had Conoco’s operations

and engineering personnel been in contact with

the Patriot master earlier than they were in the

vessel’s voyage, the entire incident could have

been avoided.

To ensure that incidents or accidents like

this do not threaten the safety of Conoco vessels

and crews in the future, the Safety Board

believes that Conoco Shipping Company should

develop and implement procedures whereby

management officials communicate and consult

with shipmasters at sea in times of potential or

actual emergencies or during safety-critical

periods of a voyage. The procedures should be

directed toward facilitating timely decisions

affecting the safety of company vessels and

their crews.

International Safety Management (KM)

Code

The circumstances of this near-grounding

incident highlight the types of issues that led the

International Maritime Organization (IMO) to

adopt, in November 1993, the International

Safety Management Code for the Safe Operation

of Ships and for Pollution Prevention (ISM

Code) .20 The ISM Code recognizes and codifies

the responsibilities of shipping company

management in ensuring adherence to marine

safety guidelines and environmental protection

standards.

A dominant theme of the ISM Code is

accountability, which, according to the IMO,

can no longer be limited to shipmasters and

crews, but now must extend to the upper levels

of company management. The degree of

management oversight demonstrated by Conoco

Shipping Company during the incident

involving the Patriot would probably not have

met the standards established by the ISM Code,

had the requirements of the code been in effect

at the time of the incident. For example, Article

8.1 of the ISM Code states that:

The company should establish

procedures to identify, describe

and respond to potential

emerging shipboard situations.

(Emphasis added.)

Conoco Shipping Company did not have

procedures in place to recognize, assess, and

respond to the potential threat that Hurricane

Roxanne posed to the Patriot. Company

management did not become involved with the

vessel before its first encounter with the storm

(when the incident could have been avoided) or

during the critical period when the Patriot’s

fatigued master was making decisions affecting

the safety of his ship and crew.

Article 8.3 of the ISM Code states:

The SMS [the company’s safety

management system] should

provide for measures ensuring

that the Company’s organiza20Dead1ines for compliance with the ISM Code are

July 1, 1998, for all passenger ships and for oil tankers,

chemical tankers, gas carriers, bulk carriers, and cargo

high-speed craft of more than 500 gross tons; and July 1,

2002, for all other cargo ships and mobile offshore drilling

units (MODUs) of 500 gross tons or more. See appendix B

for a summary of ISM Code requirements and provisions.
22

tion can respond at any time to

hazards, accidents and emerging

situations involving its ships.

(Emphasis added.)

This article clearly extends responsibility

for responding to hazardous situations beyond

shipmasters to include shoreside management.

But because Conoco Shipping Company at the

time of this incident did not have (and was not

required to have) the well-defined “lines of

communication between and amongst, shore and

shipboard personnel” that will be required by

the ISM Code, the company was not prepared to

respond in a way that would have prevented this

incident.

The near-grounding incident involving the

Patriot demonstrates the need for the changes to

traditional lines of authority and accountability

that are called for in the ISM Code. According

to Conoco officials, the company obtained ISM

Code certification on March 13, 1997. The

Safety Board notes that Conoco Shipping

Company is among the first companies to

become ISM certified.21 The Safety Board urges

Conoco to review the safety management

system it has developed in response to ISM

Code requirements and ensure that it contains

provisions that will address the safety issues that

were identified during this investigation.

Actions Taken By Conoco Since This

Incident

Conoco Shipping Company officials report

that the company has taken the following

actions since and in response to the incident

involving the Patriot

● Issued an August 28, 1996, letter to

its fleet clarifying company policy

regarding the loading of storm

ballast;

● Issued a February 4, 1997, letter to

company shipmasters providing

them with additional guidance

21 According to records of the International

Association of Classification Societies (IACS), fewer than

5 percent of the 18,500 vessels required to comply with the

ISM by July 1, 1998, have been certified by IACS

members.

regarding the making of go/no-go

decisions in situations similar to the

one faced by the master of the

Patriot on October 11, 1995;

Held company seminars for masters, chief mates, and chief

engineers to disseminate information about this incident and to

discuss the circumstances surrounding it;

Instituted at Conoco headquarters a

new weather-tracking system that,

on a daily basis, monitors the

position of each vessel in the

Patriot-class fleet in relation to

nearby tropical storms and

hurricanes;

Installed a voyage event recorder

aboard the newest company tank

ship and developed plans for

installing such units aboard each

vessel in the company’s tank ship

fleet; and

Instituted a program to conduct

failure mode and effects analysis

(FMEA) of critical shipboard

systems to ensure that these systems

meet 1S0 9000 standards.

The Safety Board appreciates Conoco’s

proactive attitude since this incident and

acknowledges the actions the company has

already taken in response to it. These actions, in

combination with implementation of the safety

recommendations resulting from this

investigation, may be expected to prevent future

incidents of this type.

In the view of the Safety Board, the

circumstances surrounding the near grounding

of the Patriot raise serious issues of marine

safety that have application not only to the

specific company and vessel involved, but to the

marine industry as a whole. This is particularly

true in light of the fact that all ship owners

and/or operators engaged in international trade

will be required to develop safety management

systems in response to ISM Code requirements.

The National Transportation Safety Board
23

therefore believes that the International the development of appropriate safety

Association of Independent Tanker Owners decisionmaking programs, heavy weather

should disseminate to its members the facts and operations contingency plans, and safety

circumstances of this incident and the National management oversight systems in response to

Transportation Safety Board recommendations the requirements of the ISM Code.

in order to assist the organization’s members in
24

Findings

1.

2.

3.

Conoco Shipping Company, at the time of

this incident, did not have in place a

shoreside multidisciplinary team

specifically responsible for assisting and

advising the company’s masters in assessing

and responding to the risks posed by

tropical storms and hurricanes.

Had the Patriot’s master better understood

the operational limitations of his vessel, had

he known the vessel could enter an

overspeed condition, and had he considered

the effects rough seas could have on his

vessel’s ability to load storm ballast, he

probably would not have entered the Bay of

Campeche, much less continued the voyage

to Dos Bocas.

If Conoco employees and managers having

both operations and engineering experience

had been in contact with the Patriot’s

master during the critical period leading up

to the vessel’s second and more serious

encounter with the storm, these individuals

4.

5.

could have assisted the master with his

decisionmaking.

The likely fatigue of the master as a result

of his lack of rest during the protracted

emergency may well have compromised his

ability to make good and timely decisions.

Had Conoco’s operations and engineering

personnel been in contact with the Patriot

master earlier than they were in the vessel’s

voyage, the entire incident could have been

avoided.

Probable Cause

The National Transportation Safety Board

determines that the probable cause of the neargrounding incident involving the tank ship

Patriot was the master’s decision to sail his

vessel into the predicted path of a hurricane, a

decision that resulted from Conoco Shipping

Company’s ineffective management of the

movements of its vessels and inadequate

shoreside support for critical shipboard

decisions affecting vessel safety.
25

As a result of its investigation of this

incident, the National Transportation Safety

Board makes the following safety

recommendations:

--to Conoco Shipping Company, Inc.:

Develop and implement procedures

whereby Conoco Shipping Company

management officials communicate and

consult with shipmasters at sea in times

of potential or actual emergencies or

during safety-critical periods of a

voyage. The procedures should be

directed toward facilitating timely

decisions affecting the safety of

company vessels and their crews. (M97-29)

Develop and implement a heavy

weather operations contingency plan

similar to your Vessel Response Plan

that is capable of providing a timely

assessment of the risks to vessels in the

fleet operating near tropical storms and

hurricanes. The plan should, at a

minimum, (1) establish a shoreside

response team that includes individuals

knowledgeable in meteorology and in

all engineering, operational, and

commercial factors that affect the safety

of vessels in the Conoco fleet; (2)

outline the duties and responsibilities of

the response team; and (3) provide

procedures to facilitate coordination and

consultation between response team

members on shore a n d Conoco

shipmasters at sea. (M-97-30)

Amend your Dec/Engine Procedures

Manual and Fleet Procedures Guide to

ensure that shipmasters and chief

engineers assigned to Patriot-class tank

ships are aware of the potential for an

engine overspeed condition, the

circumstances under which this

condition can occur, and its effect on

vessel maneuverability. Provide the

deck and engineering officers aboard

these vessels with specific guidance

concerning the actions to be taken to

prevent a main engine overspeed

condition from developing. (M-97-3 1)

Conduct an engineering and operational

analysis of the performance of your

Patriot-class tank ships when operating

in a light ballast condition in heavy

weather and rough seas with the

objective of determining the operational

actions that should be taken to ensure

the safety of those vessels under such

conditions. Provide the masters, deck

officers, chief engineers, and

engineering officers assigned to these

tank ships with the training and

guidance necessary to ensure that they

fully understand the operational

characteristics, capabilities, and

limitations of Patriot-class vessels and

are aware of the actions that must be

taken to ensure the safety of those

vessels when operating in rough seas.

(M-97-32)

Review the safety management system

(SMS) you have developed in response

to requirements of the International

Safety Management Code for the Safe

Operation of Ships and for Pollution

Prevention (ISM Code) and ensure that

it contains provisions that will address

the safety issues that were identified

during this investigation. (M-97-33)

--to the International Association of

Independent Tanker Owners:

Disseminate to your members the facts

and circumstances of this incident and

the National Transportation Safety

Board recommendations in order to

assist the organization’s members in the

development of appropriate safety

decisionmaking programs, heavy

weather operations contingency plans,

and safety management oversight

systems in response to the requirements
26

of the International Safety Management and for Pollution Prevention (1SM

Code for the Safe Operation of Ships Code). (M-97-34)

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

JAMES E. HALL

Chairman

ROBERT T. FRANCIS II

Vice Chairman

JOHN A. HAMMERSCHMIDT

Member

JOHN J. GOGLIA

Member

GEORGE W. BLACK, JR.

Member

April 8,1997
Appendix A 27

Investigation

Conoco Shipping Company notified the National Transportation Safety Board of the

near-grounding incident involving the Patriot on Tuesday morning, October 17, 1995. Because

the incident occurred in international waters and did not involve a vessel of U.S. registry, the

National Transportation Safety Board did not have jurisdiction to investigate. However, Conoco,

concerned about the potential for damage to its ship, injuries to the crew, and damage to the

environment, and recognizing the benefits of an independent review of this incident, asked the

Safety Board to undertake an investigation and determine the cause of this incident. The Safety

Board determined that it would be in the public interest to conduct an independent inquiry of the

circumstances that led to this incident.

On October 18, 1995, a four-person investigative team consisting of an investigator-incharge, an engineering factors specialist, a human performance specialist, and a survival factors

specialist was dispatched to Houston, Texas, to be briefed by the president, Conoco Shipping

Company, Inc., and his staff. On October 19, 1995, the team joined the Patriot off Galveston,

Texas, and proceeded toward Dos Bocas, Mexico. During their 2 weeks aboard the vessel, the

team conducted numerous interviews with the crew and collected documentation concerning the

events preceding the near-grounding incident. On November 1, 1995, the team returned to

Washington, D.C.

On November 17, 1995 the accident investigation team traveled to Houston to meet a

second time with senior Conoco Shipping Company management. The purpose of the second

meeting was to interview key management staff and to collect additional documentation

concerning the operation of the Patriot. These interviews concluded the on-scene portion of the

investigation.

Conoco Shipping Company was designated as party to the investigation. No Board

Member participated in the on-scene investigation of this incident.

Appendix B 29

The International Safety Management (ISM) Code

The International Maritime Organization (IMO), in November 1993, adopted the

International Safety Management Code for the Safe Operation of Ships and for Pollution

Prevention (ISM Code). The ISM Code recognizes and codifies the responsibilities of shipping

company management in ensuring adherence to marine safety guidelines and environmental

protection standards. The stated objectives of the ISM Code (Article 1.2.1) are to:

ensure safety at sea, prevention of human injury or loss of life, and avoidance of

darnage to the environment, in particular to the marine environment, and to

property.

A dominant theme of the ISM Code is accountability, which, according to the IMO, can

no longer be limited to shipmasters and crews, but now must extend to the upper levels of

company management. Compliance with the ISM Code will require that companiesl

 develop and

maintain a safety management system (SMS) that will:

● Provide for safe practices in ship operation and a safe working environment;

● Establish safeguards against all identified risks; and,

● Improve the safety management skills of personnel both ashore and on ships.

The SMS must include the following functional requirements:

● A safety and environmental protection policy;

● Instructions and procedures to ensure safe vessel operation and environmental

protection in compliance with relevant international and domestic laws;

● Defined levels of authority and lines of communication between and among shipboard

and shoreside personnel;

● Procedures for reporting accidents and non-conformities;

● Emergency preparedness and response procedures; and,

● Internal audit and management review procedures.

The ISM Code also requires that companies appoint a “designated person” (or persons)

ashore with direct access to the highest level of management. The designee must have the

responsibility and authority to monitor the safety and pollution aspects of each of the company’s

ships and to ensure that adequate resources and shore-based support are available to maintain the

SMS.

1

Companies in this case includes ship owners, but it also includes other persons or entities who have

assumed responsibility for operating a ship or ships and, by so doing, have also assumed responsibility for adhering

to the ISM Code.
30 Appendix B

The ISM Code states that the company should clearly define and document the master’s 

responsibility regarding:

● Implementing the safety and environmental protection policy of the company;

● Motivating the crew in the observation of that policy;

● Issuing appropriate orders and instructions in a clear and simple manner;

● Verifying that specified requirements (such as marine regulations, operational

directives, etc.) are observed; and

● Reviewing the SMS and reporting its deficiencies to shore-based management.

Under procedures established by the IMO, companies that demonstrate compliance with

the ISM Code will be issued a Document of Compliance. Vessels owned and/or operated by

these companies will be issued a Safety Management Certificate to be displayed on board the

vessel. While the ISM Code was developed primarily for deep-draft ships engaged in

international commerce, its provisions might be applied to all sectors of the maritime industry,

including inland and coastal barge and towing operations.

Compliance with the ISM Code is mandatory for companies operating large vessels in

international trade. Deadlines for compliance are July 1, 1998, for all passenger ships and for oil

tankers, chemical tankers, gas carriers, bulk carriers, and cargo high-speed craft of more than 500

gross tons; and July 1, 2002, for all other cargo ships and mobile offshore drilling units

(MODUs) of 500 gross tons or more. Companies that fail to comply will be considered in

violation of the International Convention for the Safety of Life at Sea (SOLAS) and may be

prevented from trading.