Safety issues directly contributing to the accident which have resulted in recommendations

1. The procedure for a pilot/coxswain briefing prior to embarking the vessel was

not conducted efficiently. The radar equipment available in the launch was liable

to severe shadow effect while close to vessels, making the identification of navigational markers unreliable. [2.11]

Other safety issues identified during the investigation also leading to recommendations

1. From historical data, incidents in the Humber Estuary are occurring more frequently than weighted in their current risk matrix. This indicates the risk is greater than initially allowed for or that the safety barriers are insufficient or ineffective. [2.3 / 2.5.2]

2. There were no detailed marine policies applied throughout the group, which made the auditing of ports within the ABP group for compliance with the PMSC more difficult. [2.5.1]

3. Risk analysis should be reviewed as a matter of routine after any serious incident to ensure the effectiveness of the safety barriers or to evaluate the need for additional barriers. [2.5.1]

Safety issues identified during the investigation which have

not resulted in recommendations but have been addressed

1. Due to a combination of circumstances the VTS operator allowed Leonis to drift into a dangerous position close to the exit from the outbound TSS. This action was compounded by the lack of traffic information to either Leonis or Audacity about the position of the other. [2.10.1 / 2.10.4]

2. Main Highway’s transit of the precautionary area, at speed, and with substantial alterations of course during the pilot boarding operation, was not good seamanship, nor was it commented on by VTS. [2.8.1]

3. The powers of the AHM to give advice and guidance to vessels operating inside the VTS area, but outside the port limits, were not fully understood, and there was reluctance for operators to issue proactive information to vessels within the precautionary area. [2.6.1 / 2.10.1]

4. It was incumbent on VTS to ensure that its plan for boarding of pilots recognized the need for vessels arriving at the boarding area to be properly separated both geographically and in time. [2.6.2]

5. The VDR recording from Leonis was incomplete, and information regarding helm and engine status was not recorded. There were no procedures in the SMS for the use and maintenance of VDR equipment. [2.4]

36

6. Routine information broadcasts, including visibility reports, were made every 2

hours. Although several reports of reduced visibility were received, no formal re-assessment was made of the visibility in the estuary and no additional broadcasts were made. There were no formal reduced visibility procedures and no requirements for reduced visibility to be reported. [2.6.2]

7. Humber VTS had no formal procedures for the preservation of records in the event of an incident. [2.6.3]

8. Leonis altered course towards the northwest because both master and pilot were unaware of the presence of Audacity. As a result, no assessment of the risk of collision was made before manoeuvring. [2.7.1 / 2.7.4]

9. ARPA was not used effectively on either vessel to assess risk of collision. By the time the ARPA was used on Leonis, it was too late for it to provide reliable information. [2.7.4 / 2.9.5]

10. Effectively, no-one held the con on the bridge of Audacity because both the master and pilot had deferred to the other, there was no discussion or questioning of the intentions of Leonis, and at a critical time they involved themselves with tasks that were inappropriate given the impending close quarters situation.

[2.9.1 / 2.9.2]

11. The bridge on Audacity was insufficiently manned in the circumstances and conditions. It did not comply with company requirements or HES instructions to pilots, however no additional resources were requested by the pilot. [2.9.2]

12. Despite advising the pilot of Leonis that he would take action and come to the south, the pilot of Audacity did not alter course. This lack of action was not questioned by the master or the VTS operator, and the pilot of Audacity did not advise Leonis’s pilot that he no longer intended to act as agreed. [2.9.2 / 2.10.3]

13. The communication between all parties involved was unclear and prone to misunderstanding, and use of standard marine phrases was not practised. [2.10]

14. VTS operators did not consider they were able to give advice and guidance to vessels with pilots on board. It was considered that the pilot would know what he was doing and that the operator did not need to be further involved once a pilot was on board. [2.10.2]

15. Communications from the VTS operator and P/L Venus were ambiguous and confusing. They were not result orientated and did not use identifier markers. Requests for specific information were inappropriately answered. [2.10.5 / 2.11]

Recommendations

UK Major Ports Group and British Ports Association are recommended to:

2008/103 Inform their members of the MAIB’s advice that they should consider how best to review how pilots can be helped to gain proper orientation of the traffic and navigational situation prior to boarding vessels to conduct acts of pilotage.

Associated British Ports Group is recommended to:

2008/104 Develop Group Marine Policies covering headline issues which can be implemented throughout the ports within the Group. Such policies should encompass, but not be limited to, training, risk assessment, and development and promulgation of best practice.

2008/105 Develop an auditing process to verify compliance with the group marine policies, including procedures which track the status of audit findings until agreed

corrective actions have been implemented.

LOSS OF TUG FLYING PHANTOM WHILST TOWING THE RED JASMINE IN FOG.

www.maib.gov.uk/cms_resources/Flying%20Phantom.pdf

SYNOPSIS

On 19 December 2007, the tug Flying Phantom was girted and sank while acting as a bow tug. She was assisting the bulk carrier Red Jasmine during a transit of the River Clyde in thick fog. Three of the tug’s four crew were lost; only the mate managed to escape from the tug’s wheelhouse and was subsequently rescued.

After Flying Phantom’s tow line had parted during the capsize, the pilot on board Red Jasmine completed the transit to the berth safely, in the thick fog, with only a stern tug to assist him.

The investigation has identified a number of factors which contributed to the accident,

including:

• The emergency release system for the towing winch on board Flying Phantom had operated, but not quickly enough to prevent the tug from capsizing.

• There were no defined operational limits or procedures for the tug operators when assisting/towing in restricted visibility.

• The routine observed by the tug’s crew prior to towing or entering fog was ineffective, resulting in the watertight engine room door being left open and the crew not being used in the most effective manner once the fog was encountered.

• The port risk assessment was poor, and the few control measures that had been put in place after a previous similar serious accident in thick fog proved ineffective.

• The port’s reliance on their ISO9001 quality management system audits to highlight safety concerns was fatally flawed.

• The lack of an individual to fulfil the role of “designated person” had resulted in major shortcomings in the port’s safety management system being overlooked.

• UK ports appear to have been failing to learn lessons from accidents at other ports.

• The lack of an accepted international industry standard for tug tow line emergency release systems.

CONCLUSIONS

Safety issues directly contributing to the accident which

have resulted in recommendations

1. Although the tow line emergency release mechanism operated after the mate activated the system, it did not act quickly enough to prevent the girting of Flying

Phantom. [2.4.1].

2. Towing winches are not generally regarded as equipment that should be the subject of class surveys. Additionally, there is no clear standard defining the time or loading within which the towing winch brake should release. [2.4.3]

3. There were no defined limits for tug towing operations in restricted visibility. If fog was encountered, there was no appropriate procedure or training provided to ensure tug crews could continue to operate safely. [2.5]

4. In the event of encountering fog, the bridge ergonomics of Flying Phantom were not suited to conducting blind pilotage operations. [2.5]

5. There were no formal pre-towing checks to ensure the necessary preparations had been completed prior to towing. This resulted in the engine room watertight door being open, which reduced the tug’s residual stability and, therefore, her ability to right herself when experiencing a heeling load. [2.6.1]

6. Once Flying Phantom had entered the fog bank, her personnel were not used to best advantage to ensure the vessel navigated safely in the narrow confines of the

River Clyde. [2.6.2]

7. Clydeport had no effective system for assessing the risk of fog. Although the area in which the accident occurred was known to be susceptible to fog, there was no reliable means of detecting the arrival of fog on the River Clyde, or warning river users of its presence. [2.7.3]

8. While a procedure for operating in restricted visibility was provided in the port’s safety management system, it was ineffective. Specifically, although a lay-by berth was detailed for consideration, it was not appropriate for a vessel of Red Jasmine’s size, and the pilot had little choice other than to continue to the ship’s intended destination, at Shieldhall Riverside Quay [2.7.4]

9. Clydeport’s risk assessment was immature, and many of the control and counter measures put in place were ineffective. It is vital that a comprehensive review of the port’s risk assessment is conducted urgently by an independent marine expert to rectify this position. [2.8.1]

10. Many of the recommendations from the Abu Agila accident, which occurred in thick fog, were not followed up, and the subsequent control measures were not implemented or were ineffective. [2.8.2]

11. There were a number of inconsistencies and conflicts within Clydeport’s SMS documentation. These had the potential to cause confusion and permitted too much flexibility in interpretation. [2.8.3]

12. Clydeport’s ISO9001 audits were not effective at highlighting any gaps in safety procedures or the adequacy of the safety procedures in place. Furthermore, the audit approach did not provide a means of checking that the underpinning risk assessments were adequate. [2.8.4]

13. Clydeport’s board was receiving a false impression of the safety performance of the port by relying on the ISO9001 system acting as the designated person. Given the safety management system shortcomings identified in this investigation, it is considered essential that Clydeport needs to appoint an appropriately qualified individual to the post of designated person under the Port Marine Safety Code. [2.8.5]

Safety issues identified during the investigation which have

not resulted in recommendations but have been addressed

1. The liferaft painter was attached to the tug directly without a weak link. Although having no bearing on this accident, if Flying Phantom had been lost in deeper water, the liferaft, even if it had inflated, would have been lost with the tug. [1.7.7]

2. Lessons from an accident at one port are not always being learnt by other. [2.9]

Recommendations

Clydeport Ltd is recommended to:

2008/161 Appoint an appropriately qualified individual to the post of designated person under the Port Marine Safety Code.

2008/162 Conduct an urgent review of its port risk assessment and safety management system to ensure:

• Requirements, conditions, controls and operational limitations for the safe transit of large vessels on the Clyde are clearly defined.

• Ambiguities or conflicts within its SMS documentation are removed.

• The company’s SMS is subject to routine audits by an independent and appropriately qualified marine professional.

• Limitations and/or working procedures relating to the operation of tugs in restricted visibility are agreed with the port tug operators and incorporated into standard operating procedures.

Lloyd’s Register is recommended to:

2008/163 Take forward a proposal to IACS to develop a standard for tug tow line winch emergency release systems, to ensure tow lines can be released effectively when under significant loads in an emergency.

Svitzer Marine Ltd. in association with the BTA is recommended to:

2008/164 Derive limitations and associated necessary guidelines and training for the operation of tugs in restricted visibility. Ensure that ports and pilots are aware of such limitations and guidelines.

The British Tugowners Association is recommended to:

2008/165 Highlight to its members the importance of tug crews’ emergency preparedness, including:

• maintaining watertight integrity

• functionality of tow line emergency release systems

• limitations and procedures for operating in restricted visibility