State administration of work safety supervision released 20 000 words of Yangtze

June 1, 2015 21 o’clock about 32 points, Chongqing East ship company belongs “East of Star”, passenger by Nanjing to Chongqing, dang sailing to Hubei Province, Jingzhou city, Jianli Yangtze River big horse Chau waterways (Yangtze River Middle Channel mileage 300.8 km at) Shi capsized, caused 442 people death (incident Shi ship Shang total 454 people, by parties full search-and-rescue, 12 people survived, 442 with victims remains all found).

After the incident, the CPC Central Committee and the State Council attach great importance to. XI Jinping, Secretary immediately issued instructions requiring that rushed to the scene to guide the rescue work of the Working Group of the State Council, Hubei Province and Chongqing municipality, and organize enough forces to conduct search-and-rescue, and do a proper rehabilitation. Meanwhile, deep learning, strengthening all aspects of measures to maintain public security and ensure the safety of people’s lives. Prime Minister Li keqiang immediately instructed the Ministry of transport and other interested parties quickly mobilized all the forces that could be mobilized, racing against time to hurry up search and rescue personnel, minimizing casualties, as well as timely treatment saved. On June 2, Prime Minister Li keqiang rate of relevant departments of the State Councilor Ma Kai, Deputy Prime Minister, Yang Jing, and responsible comrades, emergency officers sped to the scene to direct the rescue and emergency work. On June 4, the General Secretary, XI Jinping, Li keqiang, the Prime Minister has chaired a Politburo Standing Committee meeting and the Executive meeting of the State Council, stressed the need to organize the expert, in-depth analysis, adhere to based on the facts, did not miss a trace of doubt, completely identify causes, with a high degree of responsibility to strengthen safety production management.

According to Central, and State led comrade important indicates instructions spirit, by State approved, established has State “East of Star”, passenger capsized event survey group (following referred to event survey group), by security regulatory General led, industrial and information Department, and Ministry of public security, and wing, and traffic Transport Department, and China Meteorological Bureau, and National Union, and Hubei Province and Chongqing, concerned composition, and hired domestic meteorological, and shipping security, and ship design, and water Shang traffic management and information, and legal, aspects academician, and experts participate in.

Event survey group insisted “Science rigorous, and law according to rules, and facts, and focused on effectiveness” of principles, overcome various exception difficult, continuous combat, tightly around “wind, and ship, and people” three a key elements, analysis Combs out social focus concern of related problem, constantly full strengthening survey power, adjustment perfect survey work programme, in-depth carried out talk inquiries and exploration forensics, using science means analysis argument. Survey during, has access has ship, and enterprise and units of large original information, collection summary various evidence information 1607 copies, and 7.11 million word; on survived passenger, and Captain, and crew and the with waters adjacent ship about personnel and witnesses for one by one survey forensics, formed more than 500,000 word of asked record; Organization experts on ship for has detailed full exploration, and delegate specialized on evidence for interpretation identification; adjustable take ship automatically recognition system (AIS), and Global positioning system (GPS) data making ship track figure, has times for has wind tunnel wind contains model test, and pool pour airlines manipulation model test, and navigation simulation device simulation simulation test, restore has incident Shi meteorological, and ship driving and crew operation process; delegate third party institutions on ship built and previous alterations and incident Qian real contains state of stability sex for has seriously complex school accounting; on incident wind disaster near 360 square km range within of 14 a focus regional for has more round field exploration and air airlines took, Adjustable take meteorological satellite, and weather radar, and ground weather station, observation information for integrated analysis, has 7 times organization Peking University, and Nanjing University, and disaster weather national focus laboratory, and, Chinese Academy of Sciences atmosphere physical Institute and China Meteorological Bureau, Shang hundreds of both at home and abroad experts with for topic research, in integrated analysis meteorological satellite, and new more general Le radar and ground meteorological automatically station minutes level observation data, and site survey situation, and witnesses record, variety information of based Shang, science judge has incident Shi of weather status. Investigation group has convened the meeting more than 200 times, repeated research survey, was formed on the basis of this report. Now the reports are as follows:

, Event basic information

(A) “star of the East”, passenger ships.

“Star of the East”, passenger (hereinafter “Orient Star” wheels) for all of Eastern shipping company of Chongqing Yangtze normal passenger ships. Details are as follows:

1. main technical parameter. “Star of the East” end of round pointed bow double Stern pair of steel ships. On checking, ships with a total length of 76.50 meters, 66.00 meters long between perpendiculars, beam: 11.00 m, largest ship 12.40 meters wide and 3.10 meters deep, the largest ship 18.60 meters high, with a displacement of 890.602 tons, full load draft 2.16 meters, with a total tonnage of 2200, host 441.00 kW rated power X2, passenger 534 people, the crew fixed 50 people.

2. certified. After investigation, the “Orient Star” wheels are complete and valid statutory certificates. The round has ship nationality certificate ship minimum security distribution Member certificate River ship airworthiness certificate rivers and the three gorges library district ship sailing certificate River ship prevent life sewage pollution certificate River ship prevent oil certificate River ship tonnage certificate River ship load line certificate River ship passengers fixed certificate meet proved (copy) security management certificate.

3. the navigation area. Ship inspection Bureau in wanzhou, Chongqing City Bureau of shipping “Orient Star” approved of the airworthiness certificates for inland waterway vessels issued by the round area b area (to the Jiangyin Yangtze River Bridge of lidu Changjiang River Bridge in Fuling), J2 (Jet Airways). Waters of the incident, a b-grade area, navigation area, consistent with the approved area requirements.

4. loading. “Star of the East” round of the inland vessels of a passenger certificate authorized patronage of 534 people, crew of 50 people. After investigation, the actual on Board at the time of the incident to 454 people, including 408 passengers and a crew of 46 people, actual capacity in line with the requirements of the inland vessels of a passenger certificate. Ships by Nanjing at the time, enshrined in the visa application form in voyage of the ship bow draft 2.10 m, Stern draft 2.10 m, the maximum draft approved by the wheel is not super.

5. marine equipment. “Star of the East” round of records of the inspection certificate for inland waterway vessels equipped with the following equipment:

(1) navigation equipment: AIS (class b), 1 GPS devices 1, sounder 1, navigation, radar, 2 ECS (electronic chart system), 1 light 3.

(2) radio equipment: VHF phone 2, portable VHF radio telephone 2, external PA 1.

(3) main engine, steering gear and electrical equipment: host, 2 sets of 2 sets of rudder equipment, electro-hydraulic steering gear type, emergency power batteries, type of auxiliary steering gear power steering.

By sinking cab, engine control room, engine and steering gear for on-site inspection, turn main engine and auxiliary machine, rudder equipment, radio equipment, navigation equipment and signal equipment. The surviving crew members during investigation, the equipment in the flat condition normal.

6. the crew availability. “Star of the East” was the vessel’s minimum safe manning certificate requirements, which should be equipped with: master 1, Chief Officer 2, two 1, mariners 6, Chief Engineer 1, second engineer 1, mechanics 1, passenger minimum manning 11. A total 24 people.

After investigation, the facts of the voyage is equipped with a crew of 46 people, including Captain 1, Chief 3, mariners 7, Chief Engineer 1, second engineer 1, second engineer 1, third Assistant Engineer 1, mechanics 3, electrical 1, passenger Department, 27. Number of crew, duties meet the round of minimum safe manning requirements.

7. certified crew on duty. Master, Chief Engineer, chief mate and second engineer on duty in “Orient Star” wheels has a long experience.

Captain Zhang Shunwen, born in December 1963, class of master from Chongqing to Shanghai Airlines (Chongqing wanzhou maritime Department on June 23, 2011 renewal, certificate number: S512201196312282112); work 32, Captain of the 17; 7 served as a captain on the ship, since December 2007, as “star of the East” long ship.

Class mate Liu Xianlu, born in September 1962, class of Chief Officer certificate from Chongqing to Shanghai Airlines (Chongqing wanzhou maritime Department on June 23, 2011 renewal, certificate number: S512201196209021918); employed 24, Chief Officer of 12, mostly in the “Orient Star” wheels.

Chief Engineer Yang Zhongquan, born in January 1970, holds a kind of Chief Engineer’s certificate (Chongqing wanzhou maritime Department on June 16, 2011 renewal, certificate number: S510212197001214536); 25 practitioners, Chief Engineer of 13, since January 1996 in “Orient Star” wheels.

The second engineer on duty Cheng Bo, was born in January 1982, holding a second engineer certificate (Chongqing wanzhou maritime Department issued on December 12, 2012, certificate number: S511202198201242518); employed 14 April 2008 to December 2012 “star of the East” was appointed engineer, second engineer, since in January 2013.

(B) ship design and building conversions.

1.1994 initial construction. “Star of the East” round on February 1, 1994, built and completed. Ships with a total length of 62.00 meters, 55.00 metres between perpendiculars, beam: 11.00 m, largest ship 12.40 meters wide and 3.10 meters deep, with a displacement of 657.75 tons, gross tonnage of 1563, host 441.00 kW rated power X2, passenger, 584. Ship design unit for the Yangtze River shipping company Dongfeng shipyard Chongqing Dongfeng shipbuilding Design Research Institute, review drawings for Chongqing ship inspection, building inspection unit for inspection by ship inspection department in Wanxian in Sichuan province. Built shipyard include: hull section to the State-run shipyard in East Sichuan and other parts of Sichuan province, Eastern shipping company shipyard. On December 16, 1993 the ship tilt test, stability criterion results in line with the Yangtze River ship stability and load lines regulations (1985) and the 1988 change notification requirements. Inspection by ship inspection department in Wanxian, Sichuan province, on June 4, 1994 as “star of the East” was issued a ship inspection certificate.

2.1997 conversions. “Star of the East” round, in September 1996, the State-run Chongqing shipyard for alterations, completed on April 30, 1997 rebuilt. Rebuilt the vessel overall length 14.50 m, length between perpendiculars 11.00 metres, flat bow double Stern single steel ships into a sharp double Stern double bow at the end of the end of steel ships, passenger, 744. Reconstruction design of the ship for ship design Institute of Chongqing Dongfeng shipbuilding industry company, drawing review unit for inspection by ship inspection department in Wanxian in Sichuan province, conversion testing unit for inspection by ship inspection department in Wanxian in Sichuan province. Transformation shipyard include: hull section to the State-run shipyard in Chongqing, Eastern shipping company shipyard in other parts of Sichuan province. On April 25, 1997 for the tilt table test, stability criterion results in line with the code for inland waterway ship stability (1993). Inspection by ship inspection department in Wanxian in Sichuan province on June 22, 1997 for the ship inspection certificate is issued by the round.

3.2008 a facelift. This improvement is mainly in the case of hull does not changed increase passenger compartments level, and the prevention of pollution by sewage systems. Design for Chongqing wanzhou ship design center access Asia limited liability company, review drawings for Chongqing register of shipping, vessel inspection for ship inspection Bureau in wanzhou, Chongqing City Bureau of shipping. In July 2008, Chongqing Oriental re application for a passenger shipping company, ship inspection Bureau in wanzhou, Chongqing City Bureau of shipping performs additional tests to check again the integrity, stability criterion results in conformity with the technical regulations for statutory survey of inland waterway vessels (2004). On July 16, 2008, ship inspection Bureau in wanzhou, Chongqing City Bureau of shipping for the wheel reissue certificate of inland ship passenger (passenger 534).

4.2015 a facelift. 2014 “Orient Star” ships long Zhang Shunwen, visitors who repeatedly reflected the domestic water shortage, bilge water tank volume is small and serious leakage from, make changes to the Corporate Security Department water tank and ballast tank requirements. February 28, 2015, Chongqing East ship company in no examination of situation Xia, on “East of Star” round end of class of ballast class and water class for change, will ship Hou Department main deck Xia two a water class (5-16 rib bit) change for empty class, ship Qian Department main deck Xia 94-104 rib bit at 2 a ballast class and 2 a adjustable contains class change for 3 a water class and one adjustable contains warehouse.

5. ship stability analysis. Incident investigation was commissioned by professional bodies to “star of the East” round of initial construction, 1997 alteration, that in 2008, June 2015 ship technical condition of checking the wind pressure stability criterion (loaded pressure stability criterion in Hong Kong school results are shown in table 1). Results showed that, after alterations, adaptation and change three times, the wind pressure stability criterion number is greater than 1, in line with the requirements of the technical regulations for statutory survey of inland waterway vessels, ship wind pressure stability criterion number gradually decreased.

State administration of work safety supervision released 20,000 words of Yangtze River shipwreck survey: 43 officials punished

Table 1: the “star of the East” was full of wind pressure in Hong Kong stability criterion number school results list

(C) Eastern shipping company in Chongqing and shipbuilding units.

1. Eastern shipping company in Chongqing. The company is the State-owned assets supervision management of State-owned enterprises in wanzhou district, Chongqing. Its predecessor was founded in 1967 in Wanxian, Sichuan province, the shipping company, renamed in 1997 for Eastern shipping company in Chongqing. Company licensed projects include tourism transport (Chongqing, Nanjing Yangtze River foreign cruise ship transportation, Chongqing, Nanjing, ordinary passenger transport) and repair general business items include ships designed, built, and so on. Company’s existing “Emperor of the East,” three-star foreign cruise ship 1, series of domestic cruises 5. Main business, Chongqing, Nanjing, Chongqing, Yichang, wanzhou-Yichang route travel. Company Ministry of transport and waterways of the Yangtze River shipping administration issued licenses and the Yangtze River Maritime Safety Administration issued a document of compliance for safety and pollution prevention.

2. ship construction units. State Chuandong shipyard (on September 30, 2009 restructuring changed its name for Chongqing Chuandong ship heavy workers limited responsibility company) bear has 1994 years “East of Star” round main hull initial built work; State Chongqing shipyard (2007 has bankruptcy and cancellation registration) bear has 1997 years alterations main hull part; Chongqing East ship company repair shipyard (original for Sichuan province East ship company repair shipyard), is Chongqing East ship company features repair shipyard, bear has 1994 years “East of Star” Round of initial construction machinery, steering gear, wiring and carpentry, 1997 conversion of some items of equipment installation and cabin wood repair, 2008 reconstruction of the cabin layout adjusting, etc. After investigation, the shipyards above the commitment to work in line with the corresponding period of the mandate of the qualification requirements.

(D) the weather conditions.

1. weather conditions before and after the incident. Led by the Chinese Academy of engineering academician two Meteorological survey team of weather experts at home and abroad, in the comprehensive analysis of meteorological satellite and weather radar, lightning detection, automatic meteorological observation, aerial scene investigation information and the parties on the basis conversation transcripts, restored the weather conditions before and after the incident, and formed the following conclusions:

June 1, to 22:00, the “star of the East” round of navigable waters over the squall line weather system, this system is accompanied by riot hit down streams, tornadoes, short-time strong precipitation such as local, unexpected severe convective weather, suffered heavy rain and strong wind hit the waters of ferry capsizing. (Note: the thunderstorm squall line is made up of many monomers linked together and arranged laterally and the formation of convective cloud bands. Strike suddenly and violently flow refers to a thunderstorm under strong localized Downdraft, will produce a straight line winds after reaching the ground, closer to the ground wind speeds greater, maximum ground wind up to level 15)

21:00 to 21:17, “East of Star” round sailing waters for partial South, wind General is unlikely to, instantaneous great wind speed for 6.3-10.2 m/s (wind 4-5 level); about 21:18, “East of Star” round sailing waters by squall line weather system effect, wind began increased, wind to Northwest, 21:18 to 21:25, instantaneous great wind speed up 24.6 m/s around (wind 10 level); about 21:26, “East of Star” Round navigable waters affected by hit down suddenly and violently flow, affecting about 6 minutes, during this period, wind is further increased, instantaneous maximum wind speed of 32-38 m/s (wind 12-13).

From 21:00 to 22:00, the “star of the East” round of overturning waters of short time heavy rain accompanied by lightning, 1-hour accumulated rainfall reached 94.4 mm, 1 minute maximum rainfall of up to 2.6 mm. (Note: the 24-hour rainfall exceeding 50 mm for heavy rain, over 100 mm rain)

2. squall line weather system. According to the analysis of satellite and radar monitoring data analysis, June 1, 16:00, convective clouds generated in the South-Central Hubei Province area, just slightly moving South and East, 21:15 to 21:55 convective cloud to the most powerful stage of development (see Figure 1). In the convective clouds, the “star of the East” round over navigable waters the squall line weather systems, squall line width of 20-30 km, 80-100 km in length, its radar echo intensity more than 45dBZ, the transit from 21:18 to 21:55.

State administration of work safety supervision released 20,000 words of Yangtze River shipwreck survey: 43 officials punished

Figure 1: June 1 21:30 satellite infrared imagery (left) and radar echo intensity diagram (right)

3. hit down suddenly and violently flow. According to Yueyang more general Le weather radar (from incident locations 50-kilometer) observation information analysis, 21:26:32, radar measuring to of 700 meters height Shang of radial wind speed in not to 6 minutes within by 12 m/s increases to 17-20 m/s, according to meteorological experts integrated radar observation, and site disaster survey and the party and witnesses talk record analysis judge, “East of Star” round capsized waters suffered Xia hit storm flow effect.

According to the study, click under critical flow velocity increases rapidly decrease with height, according to model ground instantaneous maximum wind speed of about 32-38 m/s (12-13). Addition, according to meteorological experts site survey and airlines took get of large photos and image information analysis, “East of Star” round capsized waters on both sides of 5-kilometer range within appeared has more at suffered Gale damaged regional, many diameter size varies of trees was Middle broken, acres woods and corn lodging, which waist Tan (from “East of Star” round capsized location 0.6 km right bank) diameter for 20 cm of trees was Middle blow broken, also further confirmed has instantaneous great wind for 12-13 level. According to radar radial velocity diagram (see Figure 2) shows that, under the strike storm flows about from 21:26, around 21:32 less lasting impact for about 6 minutes.

State administration of work safety supervision released 20,000 words of Yangtze River shipwreck survey: 43 officials punished

Figure 2: June 1 to 21:32 radar radial velocity of Yueyang (0.5O elevation)

4. the encounter before the ferry capsized struck suddenly and violently flow under effect of primary evidence. At present, the Doppler weather radar is detecting click main means of storm flows. In radar echo Shang, Xia hit storm flow main performance for following features: (1) most Xia hit storm flow often occurred in bow echo raised at and hook-like echo of hook within (or hook of around); (2) low (1-kilometer height following) radar radial speed Shang has obviously spoke bulk features, in the senior has obviously spoke collection features; (3) radar strength echo mass declined. According to Yueyang more general Le weather radar observation analysis, June 1 21:15 around, bow-like echo in Jianli southern began formed, and to East mobile, 21:20 around bow-like echo raised at approximation “East of Star” round capsized location over, 21:26 around effect “East of Star” round capsized location, in low 700 meters height (radar 0.5 ° elevation observation) suddenly appeared has level scale about 2-4 km of winds district, maximum radial wind speed reached 17-20 m/s Through vertical radar profiling, “star of the East” round 1-kilometer following strong divergence over the capsizing location features over 1.6 km and 2.4 km altitude, there is a clear flow convergence; from 21:26:32 to 21:32:16, more than 50dBZ of the radar echo height fell below 700 metres height from 5-kilometer, ECHO mass decreased significantly. These three aspects are in line with the strike suddenly and violently flow under the radar.

According to experts on field surveys and aerial photography data show that “the star of the East” round water lodged trees on the right bank of overturning directions mainly south-easterly direction towards more consistent. According to a number of parties and witnesses recalled, encountered strong winds affecting wind direction did not change after, which are in line with the linear Gale struck suddenly and violently flow under the ground sign.

Integrated radar echo characteristics mentioned above and the ground disaster investigation to determine that “star of the East” round of overturning under the waters struck suddenly and violently flow. Strike suddenly and violently flow under the “star of the East” round River near the capsized position and produces linear out divergence of wind, “star of the East” was within the scope of the right in the strong winds, prevailing wind direction is Northwest.

5. rainfall conditions. Before and after the incident, the “star of the East” was sailing waters before heavy rain, accompanied by lightning. According to the distance of “star of the East” round of overturning BU 1.5-kilometer Yueyang friendship machine automatic weather station data and radar data analysis from 21:04 rain, 21:18 started to increase, 21:24 at full intensity of rainfall, rain 22:07 end. From 21:00 to 22:00, the “star of the East” round of overturning waters cumulative rainfall reached 94.4 mm.

(E) route hydrological situation.

1. channel. Wuhan Yangtze River waterway Bureau provides information on: according to the Department of transportation approval June 2015 Ma Chau waterway maintenance 5.0 m x100 m (channel depth x wide waterway navigation). June 3, River measurement, the waters of the river width of about 1060 m. Yangtze River waterway outside the network announcement: June 1-7th largest actual maintenance 6.0 meter scale x150 Ma Chau water meters. According to the Wuhan Yangtze River waterway Bureau June 3 mapping display, was found in the waters of the incident light, obstacle, Ma Chau water Riverbed morphology, floodplain and pattern stability, flow smoothly.

Da Ma Ma Chau, Chau waterway bottom set on the left side and white buoys 11 scale 1, coastal, waterway regulation engineering construction are set dedicated 2; from bottom to top with cloth, 44th on the right River 1, big red buoy 8 Ma Chau.

2. the hydrological conditions. According to Yangtze River water Committee Yangtze River Academy of Sciences provides of information showed that: June 1 20 o’clock, Jianli flow 11700 cubic metres/seconds, Jianli level 29.77 meters, incident at South di top from water height about 10.6 meters; June 3 8:19 in incident locations upstream 400 meters at measured, Jianli flow 11600 cubic metres/seconds, section area 11900 square meters, average velocity 0.97 m/s, maximum velocity 2.34 m/s, Jianli level 30.01 meters. Reaches the incident June 3 observation of the inflow of website on June 1, traffic is very close to the velocity June 3 observation of flow rate on June 1.

3. forensic examination. By the Ministry of public security, the Hubei provincial and Wuhan City, Jingzhou Yangtze River shipping Bureau criminal scene investigation and criminal technical staff of technical experts found no traces of fire marks, bombings and vandalism.

Second, basic through

(A) the incident.

Weather, investigation of ship and vessel simulation testing under the “star of the East” round of the AIS, GPS track information, on-site investigations records and rescued the crew, passengers and crew near the waters of the incident stated, identifying the incident.

13:00 May 28, 2015, the “star of the East” round by Nanjing five horses in Hong Kong Ferry Wharf sailing upstream, plans June 7 6:30 arriving in the port of Chongqing. Sailing ship crew, 46 398 passengers; save 30 tons of fuel and water supply for 17 tons, and provided 3 tons of water, fore aft draft 2.10 m.

From May 29 to May 31, docked in Anhui, respectively on the way An Qinggang (top 10 passengers), Shi Zhong, Jiangxi Jiujiang, Hukou of Jiangxi Hong Kong, Wuhan of Hubei province.

June 1, 5:00, Hubei Chibi dock.

June 1, 11:44, “star of the East” round by Red Cliff life visiting the Jinzhou port, the weather was cloudy, wind level 2, the visibility is above 10-kilometer.

17:30, Chief Officer Liu Xianlu, helmsman and Li Mingwan, sailor Li Changhua kiln Tsui (Middle Yangtze river channel about 236-kilometer), succeeding Chief Tan Jian, helmsman and Huang Chao, sailor Xu Yiqing operations ships, a speed of about 14-kilometer/hour. The weather was cloudy, wind level 2, visibility is about 6-kilometer.

21:03, “star of the East” round voyage to “day first” near (the middle reaches of the Yangtze River waterway about 297.5 kilometers), a speed of about 14-kilometer/hour. In front of lightning in the distance, then began to drizzle.

21:18, “star of the East” round to horse Island waterways, 3rd floating (the middle reaches of the Yangtze River waterway mileage 301.0 km) nearby and encountered a squall line weather systems, wind from southerly to the Northwest, rain started to increase.

21:19, “star of the East” ship length in the room heard the sound of wind and rain increased into the cabs. At this point, the Chief Officer on duty after Liu Xianlu radar monitor Conn, helmsman Li Mingwan in the rudder, sailor Li Changhua station Bell was assisted by observation. After captain of basic information to the officer the Chief Officer to take over the command.

21:21, wind and rain increasing, instantaneous maximum wind speed reached about 24.6 m/s (wind level 10), the serious decline in visibility, the captain ordered the first mate speed reducer, micro-left rudder, breaks down to the wind to the right bank side waters. Cruising speed: 12.0 km/h.

21:22, “star of the East” round helmsman gradually steering to left full. Cruising speed: 7.5 km/h.

21:23, “star of the East” round speed decreased to 2.2 kilometers per hour. Subsequently, the speed is gradually reduced to 0-kilometer/h.

21:24, in the presence of strong wind, ship back gradually to the right rear. Backward speed of 4.0-kilometer/hour.

21:25, velocity 5.6-kilometer/hour. The captain found it in the back of the boat, command Chief added.

21:26, slow backward speed to 5.0 km/h. At this time the waters caught under the wheel strikes suddenly and violently flow attack, wind is further increased, instantaneous maximum wind speed of 32-38 m/s (wind 12-13).

21:28, Chief Officer off duty Cheng Lin, Tan Jian into the cab.

21:29, in the presence of wheel, slow backward speed to 4.0 km/h.

21:30, in the presence of strong wind and heavy rain, ship deflected relative bearing the wind increased, the ship is out of control, velocity increased to 6-kilometer/h. Subsequently, the ship suddenly tilted to the right and began to ship water.

21:31, marine engine flameout, quick yaw to the right.

About 21:32, the “star of the East” was capsized, AIS and GPS signal disappears.

The round capsized Yu Hubei Province, Jingzhou city, Jianli Yangtze River middle big horse Chau waterways 3rd, red floating are cross, cross from about 600 meters, Yangtze River Middle Channel mileage 300.8 km at (29 ° 42 ‘ 39 ″ N,112 ° 55 ‘ 32 ″ e), Hou drift more than 900 more meters to Yangtze River middle big horse Chau waterways left bank side, Yangtze River Middle Channel mileage about 299.9 km, from left bank water foam line about 130 meters at (29 ° 42 ‘ 05 ″ N,112 ° 55 ‘ 28 ″ e).

(B) investigation and analysis of the situation.

1. events. Salvage water, according to crime scene investigation, cab quartz clock time frames in the 21:33 cabin clock time fixed in 21:32. According to travel agency staff members survived Zhang stated: “about 21:23 and his wife on the phone, speak to about 5 minutes more. Call the travel agency colleague Jiang Geng interrupted, said passenger room into the rain, and quickly inform the attendant to help guests, then go to room 221. Later Jiang Geng to room 221, this time up the floor and higher, water came in, from the floor up to the ship capsized about 30 seconds of time. ” Access to Zhang Hui and his wife call records to verify, finally break calls to 21:29:44. By AIS and GPS tracks to check, “star of the East” round last one AIS signal and GPS signal in time were 21:31:49 and 21:32:02 respectively. In accordance with AIS and GPS system signal rules, “star of the East” was issued the next AIS data and GPS data points of time were 21:32:19 and 21:32:22 respectively. AIS antenna once submerged and GPS systems, will not be able to send a signal.

Through the above evidence and analysis: about 21:31, for vessel yaw to the right time about 21:32, as the ship capsized.

2. personnel to escape and was rescued. A total of 12 people survived (a crew of 6 men, 6 passengers), 7 of them swam ashore, 5 people were rescued ashore. According to the survey, escape rescue was as follows:

After the capsizing, Captain Zhang Shunwen touched the left window of the cab in the water out of the water, and seize the rudder to the stern, then swim downstream the left bank. On shore, swam ashore in the downstream direction encountered Chief Engineer Yang Zhongquan, Chief Officer Tan Jian and Cheng Lin followed the coast looking for 4 people may save other personnel, running Chongqing waterway Bureau construction vessel “Hubei Huanggang cargo 2177,” Zhang Shunwen construction personnel with mobile phones to the Yueyang Maritime Bureau and the Chongqing shipping company reported the ship sank in the East.

Chief Engineer Yang Zhongquan in the engine compartment near the door on the left side of the platform at the time of the incident, conveniently caught when the ship suddenly tilted to the right near the hob, after water from the engine room door on the left side out, then climbed the ship, when the ship continues to sink off the ship swam ashore in the left bank;

Chief Officer Tan Jian in the fall when the ship suddenly tilted to the right, was swept out of the water, then swim to the bottom of the boat, while the ship continues to sink off the ship swam ashore in the left bank;

Chief Officer Cheng Lin in the wheel when suddenly tilted to the right, catch radar handrails, touch the left side of a window hole out of the water, times and drips and swim under the left bank;

Passenger Department Store service personnel when Yu Zhengwei accept clothes opened the door to the third floor deck, the ship suddenly tilted to the right will be dumped into the River, swam ashore after;

Mechanic on duty when Chen Shuhan ship tilted into the water, trapped in the engine room on June 2, were rescued by divers.

Wu Jianqiang passengers after the ship tilted to the right, handing off the window surface, lying on the bottom of the boat, then swam ashore;

Hu Jianyue passengers when the ship tilted to the right, on the third floor hallway was swept overboard, caught 2 drifting buoy, then grab a buoy mooring, Xie Longhai and passengers being rescued by coast guard boats ashore;

Xie Longhai passengers after the ship tilted to the right, was swept out of the window and water buoys seize passenger Hu Jianyue, drifting after and grab a buoy mooring, being rescued by coast guard boats ashore;

Travel agency worker Jiang Geng got life jackets in the ship’s starboard list, from the window out of the water, times and float about two hours, was rescued by a ship;

Travel agency staff member Zhang climbed out of a window when the ship’s starboard list, after drifting to the Yueyang water ashore on their own;

Passenger red beauty in the ship capsized after being swept to the linen room on June 2, were rescued by divers.

Since the incident occurred at night, outside the storm and the ship suddenly capsized after tilt, and most of the crew and passengers in the cabin, it is difficult to escape.

3. information report of the incident.

June 1, 22:10, Yueyang Maritime Bureau command center “plumber 666” was reported, saying “no 1th day” found in waters around 2 pers;

22:12, Yueyang Maritime Bureau command center inflow of Marine Department and huarong Marine Department boat rescue immediately, and contact with surrounding construction vessels participating persons in water;

23:09, report of the Office to the Yangtze River Maritime Safety Administration Bureau of Yueyang-overboard emergency information;

23:22, Yueyang report Maritime Bureau command center inflow of the Marine Department, the “star of the East” round might have an accident, later visited the Chongqing Eastern shipping company and Jianli contacted the Marine Department;

23:35, Yueyang Maritime Bureau command Center Director reporting to the head of the Maritime Bureau of Yueyang, may be the “star of the East” was capsized, followed by immediate past ships and other forces involved in the rescue of social assistance;

23:40, head of the Maritime Bureau of Yueyang and rescued the “star of the East” ship long calls, confirm the “star of the East”, has foundered in distress, then report to the Governments of Yueyang, between Jianli; then, Eastern shipping company in Chongqing Maritime Bureau of Yueyang “star of the East”, has foundered;

23:47, Jianli Yao Jian at the maritime enforcement agency, estuary, Tao saved 2 pers, recognized as the “star of the East” 2 passengers on the wheel;

23:54, report to the Yangtze River Maritime Safety Administration Bureau of Yueyang “star of the East” was capsized;

June 2, 00:10, “star of the East” to Chongqing Oriental steamship company ships long Zhang Shunwen watchman reported the ship sank, the company later launched the emergency plan, and to report to the wanzhou District Government.

00:45, the Yangtze River Maritime Safety Administration reported to the Yangtze River shipping administration event information;

00:55, the Yangtze River Maritime Safety Administration reporting event information Office of Hubei Province;

01:00, the Yangtze River Maritime Bureau reported the China maritime search and rescue Center event information;

01:15, maritime search and rescue Center of China phone event information reports the Ministry of transport and the General Office of the State Council.

4. “star of the East” round around the ship. “Star of the East” round in Malaysia state waters and five ships will ever ship.

(1) “long Jiang Ning” wheel: the wheel for ro-ro ships, carrying 682 car, upstream of Wuhan to Chongqing.

21:03, “long Jiang Ning” round voyage to “day first” near (the middle reaches of the Yangtze River waterway about 299-kilometer), the captain found the lightning and Thunder into the cab, found on their radar screen front display about 1500 metres of rain clutter, then orders the second officer on duty traffic speed dropped from 16-kilometer/hour to start.

21:07, “star of the East” round “long Jiang Ning” round of contacts, “long Jiang Ning” wheel (speed 10-kilometer km/h) tell their ship has been slow, ready to steady the ship in the front to observe the weather, such as bad weather in front of a red buoy anchor.

21:15, “star of the East” round (speed 14-kilometer km/h) is called “long Jiang Ning” wheel (speed of about 7.0 km/h) from the starboard passing.

21:20, “star of the East” round (speed 13.5 km/h) at Ma Chau near watercourses, 3rd floating (the middle reaches of the Yangtze River waterway about 301-kilometer) from “long Jiang Ning” wheel (speed 3-kilometer km/h) over the starboard side. Subsequently, the “changhang Jiangning” was under the influence of wind, begin to offset the middle.

From 21:21 to 21:28, under the influence of strong wind, “long Jiang Ning” waterways, 3rd round in Malaysia Chau floating cross 300 meters nearby waters with vehicles with rudder opposite the ship moves around. From 21:24 to 21:28, “long Jiang Ning” rear wheel to right back, backwards direction with the “star of the East” was back in the same direction for the same time period.

From 21:29 to 21:31, the captain added cars to double three wind (actual power output to 1100-kilowatt, turn at full speed for four), position to his left rear and move slowly.

21:32, hit down suddenly and violently flow began to abate, the ship gradually pulled to the right bank side.

21:39, big red float lines, Ma Zhou 3, 4th place at anchor.

(2) “Cheung Yu 9th,” cargo: the ship laden 3700 tons, since Chongqing Fengdu down to Wuhan, 21:23 Dang ship driving to big horse Chau 4th, red floating Shi, shift second mate found weather bad, will notification Captain into driving Taiwan; 21:24 the ship and “East of Star” round starboard will had; 21:26 and “long airlines Jiangning” round starboard will had, 21:40 in “long airlines Jiangning” round downstream about 500 meters at broke down.

(3) the “Hong Kong Sheng 1010” cargo ship: the ship loading 4120 tons of ore from Fuling downward to Taizhou, Jiangsu Province. About 21:18 and the “star of the East”, 3rd round in Malaysia Chau starboard float. About 21:25, ship Ma Chau, Tai, 2nd when floating, Chief Officer on duty feels it was very bad, they notified the captain on the bridge, the radar does not display correctly. Shortly after 22:40 in Han Jiazhou anchored from the “star of the East” was capsized about 10-kilometer and raw materials.

(4) “Dong Yi 99” cargo ship: the ship loaded 1400 tons of calcium carbide slag, zhicheng downward bound for Hubei hanchuan, Hubei province. About 21:21 and the “star of the East”, 3rd round in Malaysia Chau floating near the starboard; John 21:25, Chief Officer on duty saw a storm outside, they notified the captain on the bridge; after about 22 o’clock in flood waters near Hong Kong, from the “star of the East” was capsized about 10-kilometer and raw materials.

(5) “copper workers of 666” ship: the ship was unloaded, yidu, Hubei province down to Tongling, Anhui. About 21:22 ship and the captain on duty “star of the East”, 3rd round in Malaysia Chau floating near the starboard side, and shortly after 21:40 in the “star of the East” was capsized sites downstream, about 5-kilometer Ma Zhou broke down near the left bank.

5. “star of the East” round in contrast to ships in the vicinity. From 21:00 to 22:00, up “long Jiang Ning” wheel, “star of the East” round down “Cheung Yu-9th” round at Ma Chau, sailing in the waterway, caught the storm. Because the ships displacement, draught, type superstructure, wind pressure stability criterion number differences (see table 2), in the River are at different locations, leading to different results.

State administration of work safety supervision released 20,000 words of Yangtze River shipwreck survey: 43 officials punished

Table 2: main data table

“The long profitable” turn in the deceleration encountered some heavy rain and strong wind before ready to anchor and have a serious impact, the captain has taken measures to steady the ship, affected by strong wind and heavy rain also appear under the drift, back track, cruising up and down position has been in the vicinity. But its by wind surface for throughout permeability type, actual displacement is “East of Star” round of 3.3 times times, draft than “East of Star” round deep 0.49 meters, “long airlines Jiangning” round of approved airlines district for a, level, in b level airlines district suffered 33.35 m/s (12 level) cross wind Shi, lost stability sex, and “East of Star” round of approved airlines district for b level, in suffered 21.52 m/s (9 level) cross wind Shi, that lost stability sex.

“Cheung Yu 9th,” round for overload Xia sailing, speed fast, and for right stern to wind, by wind area small, coupled with actual displacement is “East of Star” round of 5.2 times times, draft than “East of Star” round deep 1.94 meters, wind pressure stability sex scale associate number over 20, ship anti-wind capacity far over “East of Star” round.

6. the crew for help and alerts. Captain about encountering extreme bad weather and lack of risk perception, are not sent out a distress call out information, not to alert the whole ship, no organizations and measures such as evacuation of passengers to abandon ship.

Three, passenger ship capsized event causes and circumstances

Investigation finds that the “star of the East” was capsized by a rare burst of strong convection weather (squall line associated with the next strike suddenly and violently flow) bringing strong wind and torrential rains cause major catastrophic events. “Star of the East” Ma Chau, sail round to the middle reaches of the Yangtze River waterway tuyu squall line weather system under this system is accompanied by strikes suddenly and violently flow, short-time strong precipitation such as local, unexpected severe convective weather. Hit by the strike suddenly and violently flow under storm surge in strength, instantaneous maximum wind reached 12-13, 1-hour rainfall amounted to 94.4 mm. Captain a steady ship wind-resistance measures, but in the presence of strong wind and heavy rain, and ship back, the ship is out of control, bow to the right wind deflection, wind heeling moment of relative bearing and air pressure gradually increase (ship gave a maximum pressure torque limit wind resistance of a ship more than twice times), the ship tilted and the water in a capsized within minutes.

Investigation team also identified the “star of the East” round enough to resist the overturning wind pressure resistance capacity encountered extreme bad weather. The round built Hou, after three times alterations, and transformation and technology change, wind pressure stability sex scale associate number successive declined, although meet specification requirements, but based on “East of Star” round of actual status, by test and calculation, the round suffered 21.5 m/s (9 level) above cross wind Shi, or in 32 m/s instantaneous wind (11 level above), wind side angle is greater than 21.1 °, and is less than 156.6 ° Shi on will capsized. The environment in which the wheel at the time of the incident and the situation is within the scope of this danger. Master and chief mate on duty on extreme weather and its lack of risk perception, inadequate response in emergency. Captain in the ship lost control overturning process, not yet been made to the ship issued a distress message and alert.

Four, check out the daily management problems in the investigation

In strict, extending investigations into the incident, the investigation team, also check out related enterprises, trade management, the local Party Committee and Government and relevant departments in the daily management and supervision of the following main issues:

Chongqing Oriental steamship company management systems, implementation is not in place. Violations unauthorized on “East of Star” round of ballast class, and adjustable contains class for change, not to wanzhou district ship test institutions application test; security training assessment work fraud, on passenger crew in bad weather situation Xia should operation training missing, on Captain, and mate, senior crew of training not real, new hired transfer personnel of assessment form; daily security checks not seriously, on ship cabin door, related facilities not by provides set rain key close device, and bed not fixed, problem troubleshooting governance not in place Ships daily maintenance and management of chaos; not establishing a vessel monitoring system, full-time monitoring, monitoring system useless, their liners are not effective implementation of dynamic tracking and monitoring, failed to detect “Orient Star” wheels have foundered.

Chongqing is the second concerning administration and local Party Committee and government supervision and control are not in place. Chongqing City port Harbor authority (Chongqing ship inspection Bureau), and wanzhou district port Harbor authority (wanzhou ship inspection Bureau) not strictly according to requirements for ship test, not found Chongqing East ship company violations unauthorized on ship ballast class and adjustable contains class for change, cabin door, related facilities not by provides set rain key close device, and bed not fixed, problem; on ship test institutions daily management not specification, on inspection ship Division management not in place; on company waterway transport license trial checks not strict, About the company’s safety management systems, implementation is not in place, crew training and examination is not implementation problems such as inadequate supervision and inspection. Traffic to the harbor of the port authority in wanzhou district, wanzhou district work safety supervision and management guidance and supervision is not in place; SASAC had not seriously implemented, wanzhou district “gang double responsibility” for companies not strict safety supervision and inspection, about the company’s training and examination fraud, problems such as inadequate supervision of safety management system in place. Wanzhou District Government in wanzhou district transport supervision of production safety Committee and other related departments are not in place, lack of water traffic safety guidance to jurisdictions.

Three is the Yangtze River shipping administration of the Department of transportation and the Yangtze River Maritime Safety Administration and under maritime law enforcement bodies on the Yangtze River maritime safety regulation is not in place. Yangtze River Harbor authority not effective implementation shipping administrative competent sector duties, handle waterway transport license work system not sound, review issued waterway transport card as checks not strict; Yangtze River Maritime Council, and Chongqing Maritime Council, and wanzhou maritime at on Chongqing East ship company security management system audit checks not strict, not seriously perform on shipping enterprise daily security regulatory duties, daily check in the not found enterprise and ship exists of security hidden and management vulnerability, problem. Maritime Bureau of Yueyang have not strictly implemented the Ministry of transport, the Yangtze River maritime affair Bureau requirements for passenger ship tracking and monitoring, tracking and monitoring system has not been established, monitors are not on duty responsibilities seriously, on the area of “star of the East” round of implementation monitoring inadequate, failing to grasp the passenger and found that the ferry capsized.

Recommendations on five, on relevant personnel and units

The incident caused heavy casualties, and social influence. Taking into account further investigation found that enterprises, administration and day-to-day management of the local Party Committee and Government and related departments have some problems, and put forward recommendations relating to personnel and units:

1. Liu Xianlu, Chongqing Eastern shipping company “star of the East” was Chief Officer on duty. In the drive in the navigation process and to extreme weather and its lack of risk perception, inadequate emergency response. Given that it has died in the incident, recommends immunity from accountability.

2. Zhang Shunwen, Chongqing Eastern shipping company “Orient Star” ships long. Enough attention to weather conditions, after entering the cab took over the ship’s command post, extreme weather and lack of risk perception, failed to detect the ship back, in control of a ship capsized in the process, no outgoing message and alert the whole ship, inadequate emergency response. According to the People’s Republic of China regulations on crew article 24th of “Captain guarantee water safety and property security, ship security, prevention of pollution from ships waters, has the right to decide independently and bear the ultimate responsibility” provisions of the proposal to revoke a master certificate of competency, termination of labor contract sanctions. Further investigation by the judicial authorities on whether the alleged crime.

3. tanyuping, the Chinese Communist Party and East of Chongqing shipping company Security Department Deputy Director and head of the system. Not carrying the water traffic management and monitoring system in Chongqing with administrative regulations, GPS management systems has not been established and staffed with full-time monitoring personnel monitoring system useless. On these issues have the primary leadership responsibility, proposed to give the party a serious warning, dismissal.

4. Hu Mingan, CCP, Chongqing Oriental steamship company of labor and personnel officer, responsible for personnel training and examination work. Not strictly implement the relevant personnel training examination and assessment requirements and standards, supervision and inspection in place, wasn’t found in time records signed on behalf of, the examination to answer questions. On these issues have the primary leadership responsibility, proposed to give the party a serious warning, dismissal.

5. Chen Yuanjian, Communist Party members, Eastern shipping company transport manager in Chongqing. Not through security checks and found no passenger beds long fixed, cabin doors not complying with the requirement of weathertight closing appliances, in the Organization of training and examination records crew exists in generation checking, examination to answer questions. On these issues have the primary leadership responsibility, proposed to give the party a serious warning, dismissal.

6. Guo Zhaoan, CCP, Director of Chongqing shipping company shipyard in the East. Change “Orient Star” hatch of wheel ballast and adjust, not implementation of the relevant provisions of the ship repair and upgrade, illegal hire does not have the special qualifications of personnel on Board of ship construction. Have the primary leadership on these issues, recommend placed on probation within the year, for dismissal.

7. Jiang Yi, Communist Party members, Chongqing Oriental steamship companies had a captain and Director of the Department of safety technology. No work responsibilities seriously and found no company training and examination fraud, passenger beds are not fixed for a long time, illegal modification of the “star of the East” round ballast and the containing class, the cabin door not complying with the requirement of weathertight closing appliances, and so on. Have the primary leadership on these issues, recommend placed on probation within the year, dismissal, revoke a master certificate of competency.

8. Hu Hongwei, Eastern shipping company of Chongqing Communist Party Committee member and Chairman of the Trade Union in 2008, has been in charge of the Department of transportation in September 2014 and in charge of the Ministry of security technology. As the company in charge of the Department of transportation, the Department of safety leadership, security, troubleshooting, such as inadequate supervision of work, training and examination fraud, GPS management provides oversight is performed. Have the primary leadership on these issues, recommends that the punishment imposed withdrawal of party posts, and by the relevant authorities in accordance with rules and procedures from the Presidency of the Union.

9. Jiang 曌, Eastern shipping company General Manager and Communist Party Secretary in Chongqing. No responsibility for safety responsibilities seriously, not importance to production safety work, violations of company unilaterally changed the “Orient Star” wheel ballast and the containing class, doors and other related facilities not complying with the requirement of weathertight closing appliances, passenger beds are not fixed for a long time, training evaluation, falsification, troubleshooting, problems such as poor management oversight. Have the primary leadership on these issues, recommended for revocation of party posts and dismissal.

10. Ping Chin, party member, vessel traffic management centers monitor Maritime Bureau of Yueyang. Passenger ship dynamic monitoring in accordance with stipulations on tourism is not a real-time understanding of vessel movement, “star of the East” was lost after failing to take effective measures to verify shipping status. Directly responsible for these problems, recommend placed on probation within the year, expelled.

11. Li Changzhi, Communist Party members, Yueyang Maritime Bureau Director of the command center. Not conscientiously implement the tourism dynamic tracking and monitoring the relevant provisions for passenger, the attendant urged the poor performance Cruiser ship dynamic monitoring responsibilities. On these issues have the primary leadership responsibility, proposed to give the party a serious warning, dismissal.

12. Du Guoping, Yueyang MSA members, Deputy Secretary of the Party Committee, in charge of the command center. To command centers in the performance Cruiser ship dynamic monitoring responsibilities of supervision is not in place, the command center staff, is not seriously implemented Cruiser ship dynamic monitoring oversight. Important leadership responsibility for the above issues, proposed to give the party a serious warnings, demoted.

13. Wan Yi, Communist Party members, b p of the wanzhou maritime Department enforcement agency supervisor, responsible for the area, such as ship safety inspection work. As the ship safety inspection supervisor, the “star of the East” round is not careful, not comprehensive, did not find the liner bed for so long is not fixed, doors and other related facilities not complying with the requirement of weathertight closing appliances, illegal modification of passenger ship ballast and the containing class, and so on. Directly responsible for these issues, recommended for demerit.

14. Fuxiang, Communist Party members, maritime supervision Bureau wanzhou, the Marine Department staff. January 2012 to May 2015, b p law enforcement deputy leader of the wanzhou maritime Department, responsible for ship safety inspection, and so on. During the Ren Longbao law enforcement deputy leader, supervisors management oversight of ship safety inspection and found no “star of the East” round bed long term is not fixed, doors and other related facilities not complying with the requirement of weathertight closing appliances, illegal modification of passenger ship ballast and the containing class, and so on. Important leadership responsibility for the above issues, proposed to give the party a serious warnings, demoted.

15. Feng Guoyong, Communist Party members, San Tin, wanzhou maritime Department Marine Patrol enforcement deputy leader. January 2012 to May 2015, wanzhou maritime Department Marine Enforcement section chief, assisting the Chief in charge of ship safety inspection, shipping companies ‘ management, and so on. Any maritime law enforcement section Deputy Chief long during, on ship security checks work urged guide poor, not found “East of Star” round bed long-term not fixed, and cabin door, related facilities not by provides set rain key close device, and violations unauthorized change passenger ballast class and adjustable contains class, problem; on Chongqing East ship company daily regulatory not in place, not found the company exists of security management system not sound, and GPS monitoring system shaped with exist, and training assessment fraud, problem. On these issues have the primary leadership responsibility, proposed to give the party a serious warning, dismissal.

16. comprehensive, Communist Party members, wushan, Chongqing Vice Director of General Office of the Marine Department. January 2013 to May 2015, wanzhou maritime Department Marine Enforcement section chief, presided. Presided over maritime law enforcement section work during, on security checks supervisor management supervision poor, on “East of Star” round bed long-term not fixed, and cabin door, related facilities not by provides set rain key close device, and violations unauthorized change “East of Star” round ballast class and adjustable contains class, problem oversight; on Chongqing East ship company daily regulatory work not in place, not found the company exists of security management system not sound, and GPS monitoring system shaped with exist, and training assessment fraud, problem oversight. On these issues have the primary leadership responsibility, proposed to give the party a serious warning, dismissal.

17. Liao Xiaoqi, wanzhou maritime Department Party Committee member, Deputy Director in charge of the maritime law enforcement branch. On maritime law enforcement section perform on area within shipping enterprise daily regulatory and security checks duties supervision management poor, on maritime law enforcement section not found Chongqing East ship company exists of security management system not sound, and GPS monitoring system shaped with exist, and training assessment fraud, problem oversight; on “East of Star” round bed long-term not fixed, and cabin door, related facilities not by provides set rain key close device, and violations unauthorized change passenger ballast class and adjustable contains class, problem oversight. Important leadership responsibility for the above issues, proposed to give the party a serious warnings, demoted.

18. pipe ambition, Chongqing chaotianmen Party Committee and Director of the Marine Department, in November 2009 to January 2015, Director of Chongqing wanzhou maritime Department. Any wanzhou maritime at Director during, on area within shipping enterprise security management system daily security regulatory, and ship security checks work management supervision poor, on Chongqing East ship company exists of security management system not sound, and GPS monitoring system shaped with exist, and training assessment fraud, problem oversight; on “East of Star” round bed long-term not fixed, and cabin door, related facilities not by provides set rain key close device, problem oversight. Important leadership responsibility for the above problem, recommended for demerit.

19. He Erjun, the Chinese Communist Party and Director of Chongqing Maritime Bureau vessel monitoring. On the area of shipping enterprise’s safety management system daily supervision and work supervision of ship safety inspection is not in place, is not effectively supervise wanzhou maritime Department of “star of the East” round of security checks, and troubleshooting management. December 2013 as Chongqing Oriental shipping company head of the annual audits of the safety management system, the company safety management system audit is not strict, failed to find head of the company’s top executive in charge of safety management does not have the appropriate professional qualification exists in name only, GPS monitoring system, training and examination fraud and other issues. Important leadership responsibility for the above issues, proposed to give the party a serious warnings, demoted.

20. Li Lu Wen, Chongqing Maritime Bureau Deputy Inspector. From August 2005 to March 2015, Member of the Party Committee of Chongqing Maritime Bureau Deputy Director in charge of the shipping authority. In charge of ship supervision during the supervision management and supervision of the ship is not in place, did not urge Chongqing Oriental steamship company on the problem of inadequate oversight of the implementation of the safety management system. Wanzhou maritime Department perform vessel safety checks and troubleshooting, management responsibility to guide supervision is not in place, to wanzhou maritime Department was not strictly in accordance with the relevant provisions of the “star of the East” was conducting security checks and troubleshooting, problems of governance oversight. Important leadership responsibility for the above problem, recommended for demerit.

21. Qiu Jianhua, Party Secretary of Chongqing Maritime Bureau Director. On the area of shipping enterprise’s safety management system and ship safety inspection, troubleshooting, governance guidelines urge is not in place, in charge of the supervision of the Deputy Secretary and the ship and wanzhou maritime Department does not fulfill the responsibility of the oversight. Important leadership responsibility for the above problem, recommends a demerit.

22. Huang Gang, Communist Party members, Deputy Director of the Yangtze River Maritime Safety Administration command center, in charge of the security alert, modern surveillance (VTS, and AIS) and so on. The Maritime Bureau of Yueyang transit Cruiser ship tracking implementation monitoring inadequate supervision and guidance at the request of, the Maritime Bureau of Yueyang command center did not take seriously its obligations under the responsibility of the oversight. On these issues have the primary leadership responsibility, proposed to give the party a serious warning, dismissal.

23. Xie Xizhou, the Chinese Communist Party and Director of maritime ship supervision of the Yangtze River. On Chongqing’s Eastern shipping company is not strict annual audits of the safety management system, failed to find head of the company’s top executive in charge of safety management does not have the appropriate professional qualification problems organizing ship safety inspection work carried out are not in place, to wanzhou Chongqing maritime safety administration, maritime ship safety inspection and troubleshooting, problems of weak governance oversight. Important leadership responsibility for the above issues, proposed to give the party a serious warnings, demoted.

24. Huan Zhao Ping, the Yangtze River Maritime Safety Administration, Member of the CPC Committee Deputy Secretary, in charge of the shipping authority. Subordinate maritime agencies shipping companies and ship safety law weak monitoring guidance, in charge of offices and personnel concerned does not take seriously its obligations under the responsibility of the oversight. Important leadership responsibility for the above problem, recommended for demerit.

25. Wang Rujun, Party Secretary, Director of the Yangtze River Maritime Bureau. Implement the national work safety laws and regulations are not in place, the leaders and relevant departments did not perform daily management, supervision and responsibility of the oversight. Important leadership responsibility for the above problem, recommends a demerit.

26. Xie Yong, party member, Deputy researcher of the Yangtze River shipping administration transport management service. Handling the Eastern shipping company in Chongqing the water transport license recertification audit work is not strict, failed to find head of the company’s top executive in charge of safety management does not have the appropriate professional qualification problems. Important leadership responsibility for the above issues, proposed to give the party a serious warnings, demoted.

27. Gan Mingyu, party branch Secretary and Director of the Yangtze River shipping administration transport management service. Has not established a system for sound card review of Chongqing Oriental steamship company the waterway transport license renewal review is not strict, failed to find head of the company’s top executive in charge of safety management does not have the appropriate professional qualification problems. Important leadership responsibility for the above problem, recommended for demerit.

28. Zhu Ruming, Deputy Director of the Yangtze River shipping administration, Member of the Party Committee, in charge of the transport management Department. The transport management office for shipping transportation business management in place, no urge in charge offices establish a water transport license renewal review system, the Department failed to find head of the company’s top executive in charge of safety management does not have the qualified oversight problems. Important leadership responsibility for the above problem, recommends a demerit.

29. Wang Xuewen, wanzhou district, Chongqing City port Harbor authority of ship inspection assistant engineer and surveyor. As a surveyor, on many occasions, “star of the East” round of the annual survey, work carefully and found no “Orient Star” marine related facilities such as doors weathertight closing device is not required, might not be discovered East of Chongqing shipping company violations unilaterally changed the ballast and the containing class, and so on. Directly responsible for these problems, recommend, institutions of the provisional regulations on disciplinary punishment imposed reducing the level of staff, revocation of teachers ‘ quality of survey.

30. the horsemen, wanzhou district, Chongqing City port Harbor authority of ship inspection engineer, surveyor. As a surveyor, on many occasions, “star of the East” round of the annual survey, not detailed, in depth and found no “star of the East” engine room doors and other related facilities not complying with the requirement of weathertight closing appliances and Oriental steamship company in Chongqing violation without authorization, remove “Orient Star” wheel of fixed ballast problem. Directly responsible for these problems, recommend, institutions of the provisional regulations on disciplinary punishment imposed reducing the level of staff, revocation of teachers ‘ quality of survey.

31. Kun, Communist Party members, wanzhou district, Chongqing City Harbor of the port authority vessel inspection section. On the spot inspection of the surveyor in the Department lacks effective supervision and management, auditing is not strict, tested by a surveyor “Orient Star” wheel, failed to find the cabin doors and other related facilities not complying with the requirement of weathertight closing appliances, illegal modification of the ballast and the containing class issues such as oversight. On these issues have the primary leadership responsibility, proposed to give the party a serious warning, and in accordance with the provisional regulations on punishment for dismissal of staff in public institutions.

32. Chen Dingke, Communist Party members, port of wanzhou district, Chongqing City, Chief of transportation management section of the maritime authority. Daily supervision of Department personnel poor management, review of Eastern shipping company in Chongqing the water transportation license is not strict, failed to find head of the company’s top executive in charge of safety management does not have the appropriate professional qualification, company safety management system is not perfect, and so on. On these issues have the primary leadership responsibility, proposed to give the party a serious warning, and in accordance with the provisional regulations on punishment for dismissal of staff in public institutions.

33. the Liu Yuan, harbor of the port authority, wanzhou district, Chongqing City Communist Party Committee member and Deputy Director, in charge of transport management branch, ship inspection Bureau. On transportation management and management in place with ship inspection, shipping companies to transport management branch review of Chongqing East of the waterway transport permit is not strict; laboratory testing of the ship “Orient Star” wheel, failed to find the cabin door and other related infrastructure issues such as not complying with the requirement of weathertight closing appliances oversight. Important leadership responsibility for the above issues, proposed to give the party a serious warning, and in accordance with the institutions of the provisional regulations on disciplinary punishment imposed reducing the level of staff.

34. Jiang Ming, port Harbor, wanzhou district, Chongqing City Party Committee and Secretary of the authority. For shipping and transportation management guidance, management and supervision in place, in charge of the Deputy Director and the departments meet vessel inspection, routine duties of supervision and inspection problems of inadequate oversight. Important leadership responsibility for the above issues, proposed to give the party a serious warning, and in accordance with the institutions of the provisional regulations on disciplinary punishment imposed reducing the level of staff.

35. Huang Changdun, Chinese Communist Party members, Deputy Director of the Chongqing port harbor transport service of the authority from April 2013 to January 2014, when the transport management office. During the Presidency, the waterways license to Chongqing Eastern shipping company review is not strict, failed to find head of the company’s top executive in charge of safety management does not have the appropriate professional qualifications, problems such as inadequate oversight of the safety management system of the company. Important leadership responsibility for the above issues, proposed to give the party a serious warnings, demoted.

36. Gu Lei, Chinese Communist Party members in Chongqing port maritime authority Director of ship inspection. Failure to carry out regular quality reviews, to wanzhou ship inspection Bureau guidance, management is not in place, to wanzhou ship inspection Bureau test “star of the East” round is not found when the cabin doors and other related infrastructure issues such as not complying with the requirement of weathertight closing appliances oversight. Important leadership responsibility for the above issues, proposed to give the party a serious warnings, demoted.

37. Zhang Yujun, Chongqing port members, Deputy Secretary of the Party Committee of the maritime authority, in charge of shipping management service. The shipping management service management and monitoring is not in place, wanzhou district of port maritime transportation Administration Guide and supervise the work of the authority is not in place, for the transport administration and harbor of the port authority in examining the Oriental steamship company in Chongqing, wanzhou district in the waterway transportation license is not strict, failed to find head of the company’s top executive in charge of safety management does not have the appropriate professional qualifications, problems such as inadequate oversight of the safety management system of the company. Important leadership responsibility for the above problem, recommended for demerit.

38. Wang Botao, Deputy Secretary, Secretary of the Chongqing port Harbor authority. On Chongqing port Harbor authority-owned Office guidance, management is not in place, port harbor transport governance and ship inspection work of the authority, wanzhou district supervision, inspection is not in place, in charge of the Deputy Secretaries of the relevant departments did not perform their duties conscientiously oversight. Important leadership responsibility for the above problem, recommended for demerit.

39. high Wu De, Chinese Communist Party members, wanzhou district, Chongqing SASAC Chief of development and security. No serious safety supervision and inspection of Chongqing Eastern shipping company, the company’s training and examination fraud, problems such as inadequate supervision of safety management system in place. Important leadership responsibility for the above issues, proposed to give the party a serious warnings, demoted.

40. fuyingquan, SASAC, wanzhou district, Chongqing City Communist Party Committee member and Deputy Director since February 2015 in charge of work safety. Urged to guide development and security section to fulfil duties of supervision and inspection of enterprises carrying out safety requirements are not in place, the in charge of the departments concerned did not fulfill the responsibility of the oversight. Important leadership responsibility for the above problem, recommended for demerit.

41. Fan Honglin, wanzhou district, Chongqing City Party Committee and Director of SASAC. Implement the national work safety laws and regulations are not in place, in charge of the leadership and the Department concerned does not take seriously its obligations under the responsibility of the oversight. Important leadership responsibility for the above problem, recommended for demerit.

42. Yang Xiaofeng, wanzhou district, Chongqing City Party Committee and Director of the traffic Committee. Port authority on navigational guidance and control are not in place in wanzhou district, wanzhou district of port Harbor authority to fulfil transportation management, supervision and inspection problems of inadequate oversight. Important leadership responsibility for the above problem, recommended for demerit.

43. Zhao Ping, wanzhou district, Chongqing City party members, Deputy Head of the Government, in charge of traffic, safety and so on. In wanzhou district traffic, safety production supervision of the relevant departments are not in place, relevant departments in Chongqing Oriental steamship company of transit management, problems of supervision and inspection oversight. Important leadership responsibility for the above problem, recommended for demerit.

44. Bai Wennong, Deputy Secretary of wanzhou district, Chongqing City, Party Secretary and head of the District Government. Implement the national work safety laws and regulations are not in place, the leaders and relevant departments did not perform daily management, supervision and responsibility of the oversight. Important leadership responsibility for the above problem, recommends a demerit. Flight attendant uncivil ridicule flights first

45. Wang Xiangang, Party Secretary of Chongqing Municipal Committee, wanzhou. Carrying out the party’s safety guidelines and policies are not in place, the wanzhou District Government and the relevant departments did not perform daily management, supervision and responsibility of the oversight. Important leadership responsibility for the above issues, proposed to give the warning within the party.

Entrusted the Chongqing, Chongqing Municipal People’s Government in accordance with the relevant provisions of the Orient steamship company ordered to, and implementation of the company Jiang Yi, Guo Zhaoan, Chen Yuanjian, Hu Mingan, tanyuping and other 5 people’s dismissal; followed by the Ministry of transport in accordance with the relevant provisions of Zhang Shunwen captain, Jiang Yi revocation certificate of competency, the horsemen, Xuewen Wang punishment by suspending teacher quality of survey.

Six, preventive and corrective recommendations

For the effective implementation of XI Jinping, General Secretary and Premier Li keqiang Central leaders ‘ important instructions instructions spirit summarized lessons, firmly establish the concept of development, improve the mechanism for improving the relevant legal system, weaving stereo Omni-directional, public safety net, further strengthening of the Yangtze River and other inland navigation safety, made the following recommendations:

(A) stricter travel restrictions on passenger ships sail the Yangtze River under harsh weather conditions … Traffic transport sector to timely released and strictly implementation Yangtze River tourism passenger bad weather conditions Xia ban limited Airlines provides, met following situation ship shall not sailing or to take other effective hedge measures: a is meteorological sector forecast or ship found starting Hong Kong has 7 level above (containing 7 level) or over ship anti-wind grade of Gale, ship must take effective avoidance, and anti-wind measures, ship shall not sailing; II is meteorological sector forecast ship via waters has 7 level above (containing 7 level) Gale or over ship anti-wind grade of Gale, Vessels must be taking shelter measures had been suspended ahead of three ship departure ports when the visibility is less than 1000 meters, ships prohibit access to the port from ships sailing downward visibility less than 1500 m or upward when the visibility is less than 1000 m, the ship must as soon as possible the optional anchor suspended.

(B) improve the technical specifications for vessel inspection requirements, improve ship design, construction and improvement of quality control systems and mechanisms. Transportation departments to research to improve inland river ships examination specification, improve River safety passenger ship wind resistance performance. Concerning ship stability and scale of alteration, adaptation should be strictly controlled and approved. Study on improve the entry threshold for ship inspection bodies. Industrial information and other competent authorities should establish and perfect ship design capability assessment and regulatory mechanisms, improve shipping conditions of construction enterprise production system, advance ship design, construction ability of dynamic assessment system, and further raise the level of standardization of ship design, construction enterprise.

(C) to further strengthen the construction of Yangtze River shipping bad weather early-warning capacities. Meteorological departments for Mesoscale Convective weather intensity big, unexpected strong, causing heavy and so on, to further increase investment in scientific research, and strengthen the monitoring and early warning method, to improve monitoring and early warning capacity. Changjiang river shipping safety and security requirements, further strengthening of weather radar and automatic meteorological stations construction along the Yangtze River, and strengthen the construction of marine automatic meteorological observation system, improving weather forecast warning capability. Perfect weather and maritime sector information sharing mechanisms, enhance nowcasting rapid release of early warning information and sound Yangtze River water transport secure VHF weather radio broadcasts, SMS and other receiving method, ensure that maritime regulators and shipping time to get severe weather warning information. Enactment of the law on prevention of meteorological disasters, and to further improve the ability to prevent weather disasters.

(D) strengthening dynamic regulation of inland navigation safety and emergency capacity-building. Transportation departments to further improve traffic flow monitoring and control measures on water, and vigorously promote the AIS, VTS and other water traffic management dynamic monitor system construction and application of information technology into full play in improving the security and the important role of emergency response capacity. Setting up key passenger ship dynamic monitoring system, arrange duty officers to strengthen the key ship, focusing on water, extreme weather shift on duty. Local governments and transportation departments to further strengthen the construction of emergency rescue system of the Yangtze River and increase investment, increase the setting of Yangtze River rescue sites, strengthening construction of the rescue team, equipped with a reasonable structure, high performance rescue equipment, improve emergency response capabilities, timely detection, rapid response, scientific rescue, logistical support.

(E) carry out the Yangtze River maritime safety campaign. Transportation departments to further strict shipping, especially passenger transport market access, strengthen the management of qualifications of operators of passenger transport dynamic tracking, strict qualification examination and qualification spot checks from time, strengthen water transport operators and passenger ship enters the market regulation. Speed up the river old passenger ship upgrades, optimizing the structure of passenger transportation, improve the safety of passenger ships. To further strengthen the management of the Yangtze River and other inland navigation safety, no tourist passenger ships sail in bad weather conditions, increase the on-site supervision and law enforcement efforts, to detect and correct shipping illegal behavior.

(Vi) strict implementation of enterprise liability, comprehensively strengthen travel safety management. Yangtze River tourism passenger company to according to safety method and water Shang traffic management of legal regulations and the regulations, strictly implementation company security management system, sound enterprise safety responsibility system, full implementation Enterprise subject responsibility; established sound this company ship limited airlines, and suspended, and broke down and the warning of system provides; strengthening enterprise employees especially crew of training assessment, for different ship, and different route, and different danger, regularly organization targeted ship Bank emergency walkthrough, constantly improve ship and shore emergency reaction capacity Used means of enterprise CCTV, GPS, AIS, on company-owned tourist passenger ships for 24-hour surveillance, enhancing ship bridge resources management, strengthening the dynamic management of marine navigation, ensure timely identifying and resolving problems in the ship.

(G) increase the intensity of river navigation seafarers ‘ skills and safety training, improving safety skills and capacity to respond to emergencies. Department of transportation-related sectors and manpower planning navigation colleges and training institutions of training and education work, improve river navigation seafarers ‘ professional training and education, and the crew test infrastructure, improve passenger ship crews checking training standards. Education, human resources and Social Security Department in crew training and social security has issued preferential policies, improving river navigation seafarers ‘ occupational attractive, improve overall quality of inland river crew especially the master and other officers and operational capacity.

The State Department “Orient Star” Ferry capsized, the investigation group

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