Dec 222008

phantomOn 19 December 2007 the tug Flying Phantom capsized on the Clyde in thick fog while assisting the bulker Red Jasmine. Of the tug’s four crew only one survived. It was a tragedy born not of single errors but of systemic weaknesses that persisted despite earlier incidents which presented lesson that no-one, apparently, was willing to learn.

Put simply, three men died because nobody listened.

Tug stability is a complex and sensitive matter. In this case, the emergency release system on the tug’s winch did not operate in time to save the vessel. There is no internationally accepted standard for tug towline emergency release systems. One does not need a tragedy to conclude that there should be.

A watertight door leading to the engine room was left open. When the vesselphantom2 capsized the engine room flooded without possibility of recovering.

Certainly there were errors aboard the Flying Phantom.

The case also calls into question the effectiveness of ISO 9001 quality management audits of Clydeport with regard to safety. The port relied upon its ISO 9001 audit by Lloyd’s Register Quality Audit  and a quality management consultant to tell it whether it was doing its job properly. The audit was not up to the task that the port assumed it was doing. The UK’s Maritime Accident Investigation Branch report comments: “The port’s reliance on their ISO9001 quality management system audits to highlight safety concerns was fatally flawed.”

As with many certificates, the ISO 9001 certificate was not an indicator that the port had the competency to carry out its safety responsibilities. Undoubtedly it looked good on the paperwork.

Surely, an essential element in a port’s QMS system is its safety management. Or should be.

Among the elements not identified as potential sources of hazard is that there were no defined operational limits or procedures for the tug operators when assisting or towing in restricted visibility.

Other elements not identified in the audit included a poor risk assessment and lack of control measures that should have been put in place following previous incidents under similar conditions.

Nor did Clydeport bother to integrate lessons learned from incidents in other ports into it safety management system. There wasn’t even a designated person in the port’s safety management system. Says the MAIB report: “UK ports appear to have been failing to learn lessons from accidents at other ports.”

Certainly, those aboard Flying Phantom made errors but it was the system itself that made their deaths a certainty and that system included the men on the Flying Phantom. Clydeport, and its QMS advisors.

This is not altogether surprising. The possession of a certificate doesn’t mean that someone can do the job, it is no proof of competency and ISO 9001 certificates are no different.

Read the MAIB Report Here.

  2 Responses to “Flying Phantom: Three Dead Because Lessons not Learned”

  1. Great report, transparency in government for once.

    However, what stikes me is that safety paperwork/procedures/ give the illusion that risks are identified and managed, and therefore in some cases actually reduce safety.

    In this case, as I read it, the fundamental problem is that the tug boats become disoriented in fog, and therefore cannot tow safely. They need some new equipment which has not been invented.

    The towed ship needs a tug to get up the Clyde (safely), so the tug cannot abandon the tow if fog descends.
    The tow cannot stop, because the tide will drop, and they can’t turn back because the channel is much too narrow.
    Since the tow operation takes 2-3 hours, fog can never be ruled out.

    The conclusion at this point should be ‘stop… no solution’ not ‘look for some control measures’.

    Fog detection would tell them fog was there, but once started towing , there is nothing they can do about it.

    Winch release mechanisms which work and closing doors might save the tug, but only after an accident has happened – changing the immediate outcome from ‘tug sinks’ to ‘large ship out of control in narrow channel’.

    ‘stop – no solution’ should lead the authorities to ‘close the Clyde until a way is found/developed to allow tugs to tow in thick fog’. But the point of the analysis was to demonstrate that what has always been done in the past was safe, not to close the Clyde.

  2. […] Flying Phantom: Three Dead Because Lessons not Learned […]

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