The loss of the “Bourbon Dolphin” Capsized April 12, 2007

[ombugge]

@Klaveness

NOU

The English version of NOU 2008:8 is available in PDF format here:
https://towmasters.files.wordpress.com/2009/03/loss-of-the-bourbon-dolphin.pdf)
It is a long report, but here is the Key Conclusions:

1.3 Key conclusions
A selection of key conclusions of the report is
here presented. The order does not say anything
about their importance in relation to the accident
and the Commission’s terms of reference.
Key conclusions are:
• The vessel was built and equipped as an allround
vessel AHSV (Anchor Handling Supply
NOU 2008: 8 15
The loss of the “Bourbon Dolphin” on 12 April 2007 Chapter 1
Vessel). Uniting these functions poses special
challenges. In addition to bollard pull, anchorhandling
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 through 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
16 NOU 2008: 8
Chapter 1 The loss of the “Bourbon Dolphin” on 12 April 2007
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.

Pretty demning, but at least some changes to the rules and practises came from this accident. Still only applies to Norwegian vessels, or vessels working in Norwegian waters, but some are working their way into IMO, IMCA and OCIMF rules and guidelines ever so slowly…

[Klaveness]

There are two more things that stood out to me.

• The oversized winch package was installed without any evaluation of the impact on stability. This is the type of customer requested modification that should have been denied, let alone implemented without further thought. The fact that Ulsteinvik walked away from that one smelling of roses is beyond me.

• The anchor handling operation was undertaken without a fully operational stability computer (I forget exactly what was up with it, it’s been a decade since I read the NOU). If it had been used to its full capacity, the captain would likely have known not to add the hair that broke the camel’s back. To me, this looks like someone dropped the ball and watched it go with a shrug.

In the end, only the last button push is remembered. I’ve discussed this one with people pretty deep in the know, including a DNV inspector, and their take on the root cause is thus: “Oh, that one is easy, she capsized because the idiot captain dropped the guide pin when he shouldn’t have”. WTF?!