This Week’s Podcast Replay: Part 2 – The Case of the Toppling Tug

 Accident, Accident Investigation, Accident report, AHTS, anchor, capsize, tug  Comments Off on This Week’s Podcast Replay: Part 2 – The Case of the Toppling Tug
Dec 152014
 

When it comes to safety, unless everybody’s on the same page
avoidable tragedies will happen.

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When the anchor-handling tug supply vessel Bourbon Dolphin capsized it came at enormous cost. Not just the loss of an almost new and expensive vessel, and a fine of more than $700,000 against Bourbon Offshore Norway, but, most importantly the loss of eight lives including that of a 14 year old schoolboy whose own life had yet to begin. It was a wake up call to the offshore industry that resonates even today.

It happened not because one man made an error but because an entire system failed to protect those onboard, because policies, procedures and practices that should have created a virtual safety net proved wanting, because not everybody was singing from the same songsheet. Continue reading »

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This Week’s Podcast: The Case of the Toppling Tug

 Accident, Accident report, AHTS, capsize, Offshore, Offshore tug, podcast, Podcasts, tug  Comments Off on This Week’s Podcast: The Case of the Toppling Tug
Dec 082014
 

Listen To The Podcast

Seven years ago Bourbon Dolphin capsized during a rig move. It was a tragedy that sent waves thorough the offshore industry but have the lessons been learned?

It is still dark early on the morning of 30th March 2007 in Scalloway, Shetland as Norwegian Captain Oddne Remoy boards the Bourbon Dolphin for the first time. Bourbon Dolphin is less than a year old, painted in the distinctive green and white house colours of Bourbon Offshore Norway. She flies the Norwegian flag.

Remoy is to relieve from the vessel’s existing master, Frank Reiersen, as part of the vessel’s shift – five weeks on and five weeks off and is replacing the ship’s other regular master, Hugo Hansen.  Hansen and Remoy have already discussed Bourbon Dolphin by telephone. Continue reading »

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Maersk Champion Fire – The Burn In The Box

 Accident, Accident report, AHTS, fire  Comments Off on Maersk Champion Fire – The Burn In The Box
Jan 022013
 
No-one knows for sure how chlorine granules reacted with the box contents.

No-one knows for sure how chlorine granules reacted with the box contents.

Nobody knows precisely how a box of discarded medical and chemical residues ignited and caused a serious fire on the AHTS Maersk Champion on 12 January 2012, says a report from Denmark’s Maritime Accident Investigation Board, but the incident raised a number of notable lessons, from the discarding of waste to potential problems refilling SCBA gear.

The fire in the ship’s hospital occured   while Maersk Champion was engaged in tanker lifting/heading control off the Brazilian coast.

Says the DMAIB: ‘The cause of the fire was most likely self ignition by a chemical reaction between chlorine-containing granules and other chemical substances in a plastic box with medicine and chemical
residues located in the ship’s hospital”.

Outdated medicine, aluminium containers with insecticide and plastic containers with chlorine containing granules had been collected and contained in a plastic box to be taken ashore. Everything contained in the box was packed and wrapped. A few hours later  fire broke out at the site of the plastic box.

A matter of concern, although it did not affect the firefighting was difficulty accessing the air compressor to refill bottles being used by firefighter

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MAIB Catches A Bit Of Sleep

 AHTS, collision, contact, fatigue, grounding, maritime safety news, stress  Comments Off on MAIB Catches A Bit Of Sleep
Aug 202011
 

Fatigue or sleep inertia?

Sleep and fatigue are familiar tropes on MAC posts and two recently released reports from the UK’s Marine Accident Investigation Branch highlight two issues, one familiar, the other less so – stress, fatigue and sleep inertia.

In the case of the FV Jack  Abry II grounding on the Isle of Rum, 31 January 2011, the skipper, who had been alone on watch in the wheelhouse, fell asleep and failed to make a course alteration. He had joined the vessel in Lochinver on the day of the accident after travelling from his home in France. It is likely the skipper became fatigued through a combination of personal stress, a prolonged period without sleep and poor quality rest before leaving his home, much of it possibly connected to domestic issues.

The wheelhouse watch alarm was not used, nor was best use made of the available navigational aids and crew.

Fatigue is not just lack of sleep and heightened stress levels. The brain has a rhythm of alertness, a circadian rhythm, which can increase the effect of fatigue. Taken together these effects do not just increase the chances of falling asleep but also increase the chances of bad decision-making. In the case of FV Jack  Abry II, the skipper did not take advantage of appropriately trained crew onboard to provide additional lookout duties. Continue reading »

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Petra Frontier: Dodgy Ship+Dodgy Relationships = Fire

 Accident report, AHTS, ATSB, Australia, fire, maritime safety news  Comments Off on Petra Frontier: Dodgy Ship+Dodgy Relationships = Fire
Dec 162010
 
image

Petra Frontier - an unhappy ship

Poor relationships between officers and crew, together with bloody mindedness, meant that when a fire broke out on the AHTS Petra Frontier it was an hour before a senior officer took command of firefighting efforts, in the meantime leaving an undrilled crew working with good intentions but little effectiveness. The case highlights the link between relationships and safety.

Fortunately the incident did not become a tragedy but the potential for bad relationships to influence effectiveness a crisis is well demonstrated by The Case of the Unfamiliar Mariner.

Says the Australian Transport Safety Board report: “On 28 September, during the initial and extremely important stages of the emergency response, the master and the chief mate remained on the bridge and discussed how they should best respond to the fire, without involving or effectively directing the crew. At the same time, the crew assembled on the main deck and decided to enter the space and extinguish the fire without waiting for direction from the master or chief mate. The actions of the two groups were independent of each other. This suggests that the pre-existing inter-departmental issues were having a disruptive effect on the crew’s ability to work together as a cohesive team”.

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Accident Report – Wrong Insert Led To Anchor Handling Fatality

 Accident report, AHTS, tug  Comments Off on Accident Report – Wrong Insert Led To Anchor Handling Fatality
Apr 112010
 

image Use of an oversized, and worn, U-shaped insert in a wire stopper failed to restrain a pennant wire that came under tension, resulting in the death of an AB on an anchor handling tug, reports the International Maritime Contractors Association.

Says IMCA: “A member has reported a fatal incident which occurred during anchor handling operations. The incident occurred on an anchor handling tug (AHT) whilst crew were attempting to disconnect an anchor buoy weighing 1.4 tons from its pennant wire shortly after retrieval.

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Mar 292008
 
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No single cause led to the capsize of the AHTS Bourbon Dolphin with the loss of eight lives, with seven survivors, on April 12, 2007 says a report into the sinking released by Norway’s Justice Ministry, but Bourbon Offshore, which owned the vessel has been criticised for inadequately checking the vessel’s stability following an earlier incident and for not ensuring that the captain, Oddne Remøy, was sufficiently familiar with the vessel sand its crew before undertaking the operation that led to the capsize.

Key conclusions are:
• The vessel was built and equipped as an all-round vessel AHSV (Anchor Handling Supply Vessel). Uniting these functions poses special challenges. In addition to bollard pull, anchor-handling demands thruster capacity, powerful winches, big drums and equipment for handling chain. Supply and cargo operations demand the biggest possible, and also flexible, cargo capacities both on deck and in tanks. The “Bourbon Dolphin” was a
relatively small and compact vessel, in which all these requirements were to
be united.

• The company had no previous experience with the A 102 design and ought therefore to have undertaken more critical assessments of the vessel’s characteristics, equipment and not least operational limitations, both during her construction and during her subsequent operations under various conditions. The company did not pick up on the fact that the vessel had experienced an unexpected stability-critical incident about two months after
delivery.

• The vessel’s stability-related challenges were not clearly communicated from shipyard to company and onwards to those who were to operate the vessel.

• Under given load conditions the vessel did not have sufficient stability to handle lateral forces. The winch’s pulling-power was over-dimensioned in relation to what the vessel could in reality withstand as regards stability.

• The anchor-handling conditions prepared by the shipyard were not realistic. Nor did the Norwegian Maritime Directorate’s regulatory system make any requirement that these be approved.

• The ISM Code demands procedures for the key operations that the vessel is to perform, Despite the fact that anchor-handling was the vessel’s main function, there was no vessel-specific anchor-handling procedure for the “Bourbon Dolphin”.

• The company did not follow the ISM code’s requirement that all risk be identified.

• The company did not make sufficient requirements for the crew’s qualifications for demanding operations. The crew’s lack of experience was not compensated for by the addition of experienced personnel.

• The master was given 1½ hours to familiarise himself with the crew and vessel and the ongoing operation. In its safety management system the company has a requirement that new crews shall be familiarised with (inducted into) the vessel before they can take up their duties on board. In practice the master familiarises himself by overlapping with another master who knows the vessel, before he himself is given the command.

• Neither the company nor the operator ensured that sufficient time was made available for hand-over in the crew change.

• The vessel was marketed with continuous bollard pull of 180 tonnes. During an anchor-handling operation, in practice thrusters are always used for manoeuvring and dynamic positioning. The real bollard pull is then materially reduced. The company did not itself investigate whether the vessel was suited to the operation, but left this to the master.

• The company did not see to the acquisition of information about the content and scope of the assignment the “Bourbon Dolphin” was set to carry out. The company did not itself do any review of the Rig Move Procedure (RMP) with a view to risk exposure for crew and vessel. The company was thus not in a position to offer guidance.

• The Norwegian classification society Det norske Veritas (DNV) and the Norwegian Maritime Directorate were unable to detect the failures in the company’s systems though their audits.

• In specifying the vessel, the operator did not take account of the fact that the real bollard pull would be materially reduced through use of thrusters. In practice the “Bourbon Dolphin” was unsuited to dealing with the great forces to which she was exposed.

• The mooring system and the deployment method chosen were demanding to handle and vulnerable in relation to environmental forces.

• Planning of the RMP was incomplete. The procedure lacked fundamental and concrete risk assessments. Weather criteria were not defined and the forces were calculated for better weather conditions than they chose to operate in. Defined safety barriers were lacking. It was left to the discretion of the rig and the vessels whether operations should start or be suspended.

• In advance of the operation no start-up meeting with all involved parties was held. The vessels did not receive sufficient information about what could be expected of them, and the master misunderstood the vessel’s role.

• The procedure demanded the use of two vessels that had to operate at close quarters in different phases during the recovery and deployment of anchors. The increased risk exposure of the vessels was not reflected in the procedure.

• The procedure lacked provisions for alternative measures (contingency planning), for example in uncontrollable drifting from the run-out line. Nor were there guidelines for when and in what way such alternative measures should be implemented and what if any risk these would involve.

• The deployment of anchor no. 2 was commenced without the considerable drifting during the deployment of the diagonal anchor no. 6 had been evaluated.

• Human error on the part of the rig and the vessels during the performance of the operation.

• Communication and coordination between the rig and the vessel was defective during the last phase of the operation.

• Lack of involvement on the part of the rig when the “Bourbon Dolphin” drifted.

• The roll reduction tank was most probably in use at the time of the accident.

• The inner starboard towing pin had been depressed and the chain was lying against the outer starboard towing pin. The chain thereby acquired a changed angle of attack.

The incident was investigated by a Royal Commission which held five open hearings and questioned 38 witnesses, including the survivors, officers from other vessels that participated in the operation, individuals from the owner company, the shipyard, the operator company Chevron, the drillrig “Transocean Rather”, the UK consultancy firm Trident, and The Norwegian Maritime Directorate and the classification society Det Norske Veritas. In addition the Commission has collected and reviewed a large quantity of documentation related to the vessel and the operation in which the “Bourbon Dolphin” was involved when the accident happened. The Commission has also had access to underwater footage of the casualty taken straight after the capsize and of the wreck in December 2007. Members of the Commission have held a meeting with the parties’ stability experts and gained access to material that the latter had collected.

In its report the Commission points out that it is not possible to show that an individual error, whether technical or human, led to the accident; rather, a series of circumstances acted together to cause the loss of the vessel. The Commission concludes that the proximate causes of the accident were the vessel’s change of course to port (west) so as to get away from mooring line no. 3, at the same time as the inner starboard towing pin was depressed, causing the chain to rest against the outer port towing pin. This gave the chain an altered point and angle of attack on the vessel. Together with the vessel’s current load condition, the fact that the roll reduction tank was probably in use, and the effect on the vessel and chain of external forces, caused the vessel to capsize.

It emerges from the report that a number of indirect factors have contributed to the accident. A combination of weaknesses in the design of the vessel, and failures in the handling of safety systems by the company, by the operator and on the rig, are major contributory factors to the operation of 12 April 2007 coming out of control. Overall, system failures on the part of many players caused necessary safety barriers to be lacking, were ignored or were breached, so that the vessel and crew were exposed to a risk that resulted in the accident.

The Commission also makes a number of recommendations in its report with a view to preventing similar accidents in the future. Although no structural changes are proposed for existing vessels, it is recommended that in the future requirements are made for the preparation of stability calculations for anchor-handling that will be subject to approval by the authorities. In addition, requirements are proposed for formal training of winch operators and a review of requirements for survival suits, plus placement and installation of rescue floats. The Commission also proposes measures to improve the companies’ safety management systems. Risk assessments must be improved, there must be routines for overlap of new personnel and identification of the necessary crew qualifications, plus the preparation of vessel-specific anchor-handling procedures.

The Commission also points out that the operators’ rig move procedures must be made specific for every operation and be simple to understand for those operating under them. It must be insisted that the operator and rig prepare risk assessments for the entire operation before it is commenced. When the operation is executed, safety and coordination must be continuously evaluated. The Commission also proposes that an attention zone be introduced along the anchor line, indicating a maximum distance within which the vessel shall remain when running out anchors.

Press Conference Video

Commission Report, preliminary English Version

Animation, first sequence

Animation, Second Sequence

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Maritime Safety News Today – 30 November 2007

 AHTS, seaman  Comments Off on Maritime Safety News Today – 30 November 2007
Nov 302007
 

Have news to share? email news@maritimeaccident.org
What to report in confidence? email confidential@maritimeaccident.org

AHTS Sinks – Crew Evacuates Safely

Alam Maritim Resources Berhad HAS announced that one of its vessels had an accident on November 29, 2007.

The incident happened in the vicinity of Resak Platform while MV Setia Mega was sailing from Kemaman Supply Base to Dulang B Oilfield. The vessel had taken in a large quantity of water during an adverse weather condition and was fully submerged. The extent of the damage is still being assessed.

CREWMAN’S BODY RECOVERED AFTER FALLING FROM BARGE

The body of a crewman from the towing vessel Jeff Boat was recovered today after falling from a barge while transisting through Lock and Dam number 14 near Leclaire, Iowa on the Upper Mississippi River.

SEA-FARER’S FAMILY PLEAD FOR TRIAL TO BE MOVED TO KIRIBATI
Niu FM – Auckland,New Zealand
Auckland 6am: Talks are underway between Chinese and German authorities over the fate of a Kiribati seafarer who’s being kept behind bars in China.

UN maritime agency urges action to curb piracy off coast of Somalia 29 November 2007 – The United Nations International Maritime Organization (IMO) today renewed its call for measures to prevent and suppress acts of piracy and armed robbery against ships off the coast of Somalia. Piracy jeopardizes the delivery of much-needed aid to Somalia, which is facing a deteriorating humanitarian situation.

IMO Assembly issues renewed call for action on piracy off Somalia
Renewed calls for action to prevent and suppress acts of piracy and armed robbery against ships, in particular off the coast of Somalia, were made by the 25th session of the Assembly of the International Maritime Organization (IMO), when it adopted a new resolution on Piracy and armed robbery against ships in waters off the coast of Somalia today (Thursday, 29 November).
Ferry complaints up, along with overtime bill
Brisbane Times – Brisbane,Queensland,Australia
“There’s not enough people in the joint,” said the branch secretary of the Maritime Union of Australia, Warren Smith. “The guys are doing a 45-hour week and

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Sep 252007
 

MSF, Marine Safety Forum, has set up a work programme in response to the Bourbon Dolphin tragedy in April, 2007, to respond to industry concerns and actions raisedf by the Norwegian Maritime Directorate. A full enquiry is current underway by the NMD.

The Bourbon Dolphin, an Ulstein A102 Anchor Handling Tug Supply vessel capsized and sank during anchor-handling operations for the semi-submersible drilling platform Transocean Rather. According to report on the Marine Link websiteWhen the Bourbon Dolphin attempted to release the inner pin of the anchor, the chain ran free and caught the outer tow pin, which caused the boat to capsize. The emergency release was triggered, but did not perform as designed. Fifteen crew members were onboard, seven survived, three bodies were found, and five are still missing, thought to be trapped in the vessel.”

Only one member of the bridge team survived.

Pending release of a full report the NMD has released a series of measures for Norwegian-registered vessels intended to avoid similar incidents. Copies are available here.

Bourbon itself has established a fund of the families of those lost in the incident .

MSF will hold a workgroup review meeting in Aberdeen on 28 November 2007, preparatory to the MSF all members meeting on the 29th.

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