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7/21/2019 The Loss of the Bourbon Dolphin 12.4.2007
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Official Norwegian Reports 2008: 8
The Loss of the “Bourbon
Dolphin” on 12 April 2007
NOU
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Norges offentlige utredninger
2008Seriens redaksjon:
Departementenes servicesenter
Informasjonsforvaltning
1. Kvinner og homofile i trossamfunn. Barne- og likestillingsdepartementet.
2. Fordeling av inntekter mellom regionalehelseforetak.
Helse- og omsorgsdepartementet.
3. Sett under ett. Kunnskapsdepartementet.
4. Fra ord til handling. Justis- og politidepartementet.
5. Retten til fiske i havet utenfor Finnmark. Fiskeri- og kystdepartementet.
6. Kjønn og lønn. Barne- og likestillingsdepartementet.
7. Kulturmomsutvalget. Finansdepartementet.
8. Bourbon Dolphins forlis den 12. april 2007. Justis- og politidepartementet.
Cover photo: Tony Hall.
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NOU Official Norwegian Reports 2008: 8
The Loss of the “Bourbon
Dolphin” on 12 April 2007Report from a Commission appointed by Royal Decree of 27 April 2007.Submitted to the Royal Norwegian Ministry of Justice and the Police on 28 March 2008.
Translation from Norwegian. For information only.
Government Administration ServicesInformation Management
Oslo 2008
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ISSN 0333-2306ISBN 978-82-583-0965-6
07 Gruppen AS, Oslo
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Abbreviations of the Regulations
BuildingRegulations,theCertificationAct,the
COLREG
ISMCode,the
ISMRegulations(forcargoships),theISPSCode,the
LoadLinesConvention,theLSACode,theManningRegulations,theMaritimeSafetyAct,theMARPOL73/78
NavigationRegulations,theNWEAguidelines
POSMOOR
QualificationRegulations,theRadioRegulations,theRescueRegulations,theSeaworthinessAct,the
SOLASConvention,theSTCWConvention,the
WorkandRestTimeAct,the WorkingEnvironment
Regulations,the
Abbreviations
RegulationsNo.695of15September1992 ActNo.42of5June1981onPostsrequiringCertificationonNorwegianShips TheConventiononInternationalRegulationsforPreventingCollisionsatSea,1972 TheInternationalManagementCodefortheSafeOperationofShipsandPollutionPrevention,adoptedbytheIMOin1993
RegulationsNo,822of6August1996InternationalCodefortheSecurityofShipsandofPortFacilities,2002
TheLoadLinesConvention,1966Life-SavingApplianceCode1996RegulationsNo.175of17March1987 ActNo.9of16February2007onMaritimeSafety TheInternationalConventionforthePreventionofPollutionfromShips,1973/78RegulationsNo.701of15September1992GuidelinesforthesafemanagementofoffshoresupplyandanchorhandlingoperationsNWEA(NorthWestEuropeanArea)DNV-OS-301PositionMooring.October2004
RegulationsNo.687of9May2003RegulationsNo.1855of17December2004RegulationsNo.1856of17December2004 ActNo.7of9June1903onStateControloftheSeaworthinessofShipsetc.ConventiononSafetyofLifeAtSea,adoptedbytheIMOin1974 TheInternationalConventiononStandardsofTraining,CertificationandWatch-keepingforSeafarers,adoptedbytheIMOin1978 ActNo.50of3June1977onWorkingHoursandRestTimeonShips
RegulationsNo.8of1January2005
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NOU 2 8: 8
The loss of the “Bourbon Dolphin” on 12 April 2 7
Other abbreviations
ACOP AHTS AHT
AHVBPDNVDPDTIGMGZcurveHAZIDHAZOPH&SE
IMOKGlimitcurve
LRNISNORNWEAMOB-boatMODUOIMOLFPCPPSVQAQCRMPROVSMSSOSREP
SWL
TCG
UKOOAUTC VCG
ApprovedCodeofPractice AnchorHandling,TugandSupply AnchorHandlingandTug
AnchorHandlingVesselBollardPullDetnorskeVeritas(Norwegianclassificationsociety)DynamicPositioningDepartmentofTradeandIndustry(nowDBERR) Thedistancefromthevessel’scentreofgravitytothemetacentreCurveforcorrectingarmasfunctionofheelingmomentHazardousIdentificationHazardousOperabilityHealthandSafetyExecutive
InternationalMaritimeOrganizationMaximumdistancebetweenkeel(baseline)andcentreofgravitytomeetstabilityrequirementsLloyd’sRegisterNorwegianInternationalShipRegisterNorwegianOrdinaryShipRegisterNorthWestEuropeanAreaManOverboardBoatMobileOffshoreDrillingUnitOffshoreInstallationManagerNorwegianOilIndustryAssociationPermanentChaserPennantPlatformSupplyVesselQualityAssuranceQualityControlRigMoveProcedureRemoteOperatedVehicleSafetyManagementSystemSecretaryofStateRepresentativeforMarineSalvageandInterventionSafeWorkingLoad
TransverseCentreofGravity(transversedistancefromcentrelinetocentreofgravity)UnitedKingdomOffshoreOperatorsAssociationUniversalTimeCentre(GMT) VerticalCentreofGravity(verticaldistancefromcentrelinetocentreofgravity)
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To the Ministry of Justice and the Police
TheCommissionofInquir yintothelossofthe“BourbonDolphin”on12 April2007was appointedat ameetingof theKing-in-Councilon27April2007,ontheauthorityofSection485oftheMaritimeAct.
TheCommissionof Inquiryherebysubmits its report.Thereport isunanimousonallpoints.
Keysupportingdocumentsarepublishedastwoseparateannexes.
Oslo,28March2008
IngerLyngChair
DagAndreassen GisleArnoldHansenFiksdal
GuroHøyaasLøken YngveSkovly
TerjeHernesPettersen
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6 NOU 2 2: ?
Eierbegrensning og eierkontroll i finansinstitusjoner
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Contents
1 Summary ..............................................13 3.6.2 Generalrequirementsforsafety1.1 TheAccident.........................................13 andhealth..............................................31
1.2 Thestructureofthereport..................14 3.7 Guidelinesforthesafe1.3 Keyconclusions...................................14 managementofoffshoresupplyandanchor-handlingoperations
2 TheCommissionofInquiry intheNWEA.........................................33anditswork........................................17 3.7.1 General..................................................33
2.1 Introduction..........................................17 3.7.2 Riskassessments .................................332.2 Moreonthemembersofthe 3.8 Operationalstandardsfor
CommissionofInquiry........................17 performanceofmarineoperations......342.3 TheCommissionofInquiry’s 3.9 Requirementsforthemooring
competenceandtermsofreference ...18 systemofthe“TransoceanRather”.....342.4 TheworkoftheCommission
ofInquiry...............................................19 4 Thecompany .......................................36
2.5 Collectionoftheevidence...................19 4.1 Organisation..........................................362.6 Methodologyandtheuseofexpert 4.2 Crewsduringtheoperation.................36
witnesses...............................................20 4.3 Thecompany’ssafetymanagement2.7 Thestabilitymeetingandstability system ...................................................37
calculations............................................20 4.4 Provisionalcertification2.8 Qualityassuranceandtherighttobe of3October2006..................................39
heard......................................................21 4.5 Internalauditof9March2007.............394.6 DNV’sauditof17March2007.............39
3 Regulatoryrequirementsfor 4.7 Evaluation..............................................41anchor-handlingvesselsand 4.7.1 Familiarisation/overlap ........................41anchor-handlingoperations............22 4.7.2 Identificationoftrainingneeds ............41
3.1 Introduction..........................................22 4.7.3 Anchor-handlingprocedure ................. 423.1.1 Theinternationalmaritimesafety 4.7.4 Otheraspectsofthesafetyregulations.............................................22 managementsystem............................42
3.1.2 Norwegianmaritime 4.7.5 Thecrew................................................43safetylegislation...................................23
3.2 Requirementsforthevessel’sdesign 5 The“BourbonDolphin”...................44
andequipment ......................................23 5.1 Introduction ..........................................443.3 Requirementsforthesafety 5.2 Contractingandconstruction..............45
managementsystem............................24 5.3 Thevessel’sarrangement....................463.4 Requirementsformanning 5.4 Stability...................................................49
andqualifications..................................26 5.4.1 Thestabilitybook..................................493.5 Requirementsforcontrol, 5.4.2 Controlofstabilityonboard................50
inspectionandcertification..................27 5.4.3 Theloadcalculator................................513.5.1 TheNorwegianMaritime 5.5 Theengineandpropulsionsystem ....51
Directorateasasupervisorybody......27 5.6 Winchesandother3.5.2 Classificationsocieties anchor-handlingequipment.................52
assupervisorybodies...........................27 5.7 Rescueequipmentandrescue3.5.3 TheNorwegianMaritime arrangement .........................................55
Directorate’scontrol............................28 5.8 Navigationandcommunications3.5.4 Theclassificationsocieties’ equipment .............................................55
ownworkoutsidethepublic 5.9 Manning................................................56regulatorysystem.................................30 5.10 OperatinghistoryfromOctober2006
3.6 BriefsummaryoftheBritish untiltheendofMarch2007 ................ 56
regulatorysystemfor 5.11 Evaluation..............................................57anchor-handlingoperations................31 5.11.1 Contractingandconstruction..............573.6.1 Introduction..........................................31 5.11.2 Thevessel’sarrangement....................57
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5.11.3 Stability..................................................57 8 Executionoftherigmove................805.11.4 Winchesandother 8.1 Thebriefingmeeting ............................80
anchor-handlingequipment................58 8.2 Thecrewchange...................................805.11.5 Therescueequipment.........................58 8.3 Briefdescriptionoftheoperation
upto12April..........................................816 Theplanningoftherigmove.........60
8.3.1 Introduction ...........................................816.1 Introduction..........................................60 8.3.2 Theimplementation..............................826.2 BriefdescriptionofChevron, 8.3.3 Writtendivisionoflabourfor
TransoceanandTrident.......................60 deploymentofsecondaryanchors.......826.3 The“TransoceanRather” 8.3.4 Theroleofthe“BourbonDolphin”
-specifications.......................................61 upto12April..........................................846.4 The“TransoceanRather” 8.4 Evaluation..............................................84
- personnel............................................62 8.4.1 Thebriefingmeeting ...........................846.5 Themakingofthecontractbetween 8.4.2 Thecrewchange...................................84
ChevronandTransocean.....................646.6 Choiceofmooringsystemand 9 Theaccident ........................................85
installationmethod...............................64 9.1 Introduction ...........................................856.6.1 Provisionalmooringanalyses.............64 9.2 Anchorno.6...........................................856.6.2 Finalmooringanalyses........................64 9.3 Anchorno.2...........................................866.6.3 Choiceofinstallationmethod..............64 9.4 Themorningshift..................................876.7 Therigmoveto213/26-1z 9.5 Weather,windandcurrent
Rosebank-Location“G”......................65 conditionson12April2007..................876.8 Theplanningoftherigmove 9.6 Runningofchainforanchorno.2.......88
toLocation“I”.......................................65 9.7 Theattemptofthe“HighlandValour”6.9 RigMoveProcedurefor togetholdofthechain........................89
Location“I”............................................65 9.8 Thenear-missbetweenthe“Bourbon6.9.1 Thevessels...........................................65 Dolphin”andthe“HighlandValour”...916.9.2 Recoveryofthesecondaryanchors 9.9 Theperioduptothecapsizing.............92
(nos.2,3,6and7)................................66 9.10 Forcesaffectingthevesselduring6.9.3 Recoveryofprimaryanchors theaccident............................................95(nos.1,4,5and8),towingto 9.10.1 Introduction ...........................................95Location“G”.........................................67 9.10.2 Loadcondition1,ondeparture
6.9.4 Deploymentofanchors........................67 fromLerwick........................................1016.9.5 Requirementsforbollardpull ............67 9.10.3 Loadcondition2,beforethe6.9.6 Weathercriteria...................................69 towing-pinwasdepressed..................1026.9.7 Riskassessmentsandplansfor 9.10.4 Loadcondition3,afterthe
alternativesituations towing-pinwasdepressed..................103(contingencyplanning)........................69 9.10.5 Commentsonthecalculations...........106
6.10 Evaluation..............................................70 9.11 Evaluation............................................1076.10.1 Maritimemanningonthe
“TransoceanRather”............................70 10 Therescueoperation......................1116.10.2 Choiceofmooringsystem 10.1 Introduction .........................................111
andinstallationmethod........................70 10.2 Raisingthealarm–establishment6.10.3 Therigmoveprocedure ......................71 ofrescueleadership...........................111
10.3 Thesurvivors.......................................1127 Thevessels..........................................74 10.4 Thesearchforthemissing ...............1137.1 Thecharteringofthe 10.5 TheMainRescueCentreat
anchor-handlingvessels......................74 Sola/thelocalpoliceinNorway........1157.2 Overviewtablewithkeydata..............757.3 The“HighlandValour” .......................76 11 Thesalvageattempt .........................1177.4 The“OlympicHercules”.....................77 11.1 Introduction .........................................117
7.5 The“VidarViking” ..............................78 11.2 Loginformationonthe“Bourbon7.6 Evaluationofvesselinspection ........... 79 Dolphin”untilshesank ......................117
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11.3 Eventsuntilthesalvagecontract wassignedonFriday13April...........118
11.4 SmitSalvage........................................11911.5 SOSREP–SecretaryofState
RepresentativeforMarineSalvage
andIntervention.................................11911.6 Thesalvageplan................................11911.7 SCR–SpecialCasualty
Representative....................................12011.8 Thesalvageteam(minusthe
salvagemanager)goestothesceneoftheaccident.........................120
11.9 SOSREP’sdecisiontofreethe“BourbonDolphin”fromanchorchainno.2..............................121
11.10 ThesituationonthefieldonFriday13April...............................121
11.11 Thesalvageteamarrivesonthefield...........................................121
11.12 Developmentofthecasualty’sconditiononSaturday14April..........122
11.13 The“BourbonDolphin”isfreedfromanchorchainno.2.....................122
11.14 Thesituationofthe“BourbonDolphin”deteriorates.......123
11.15 SalvageManagerJanvanderLaancomesbelatedlytothefield..............124
11.16 The“BourbonDolphin”sinks...........124
11.17 Evaluation...........................................12512 Summing-up:causes
andresponsibility ............................12712.1 Introduction........................................12712.2 Theproximateand
triggeringcause.................................12712.3 Indirectcausesoftheemergency....12812.3.1 Defectsinthevessel
andthecompany ...............................12812.3.2 Activityonboardon12April.............13012.3.3 Planningoftherigmove,including
vesselrequirements...........................13112.3.4 Theimplementation
oftheoperation...................................13212.4 Whytheemergencywas
notprevented......................................133
12.512.6
13
13.1
13.2
13.3
13.3.113.3.213.3.313.413.4.113.4.2
13.4.313.4.4
13.513.5.113.5.213.5.313.5.413.6
13.6.1
13.6.213.6.313.713.813.913.9.1
13.9.213.9.3
13.10
Deficientsafetymanagement............134Liability.................................................135
Recommendations...........................136Introduction.........................................136
TheNorwegianMaritimeDirectorate’simmediatemeasures.............................................137Stabilityofanchor-handling vessels .................................................137
Dutyofnotificationofmaritimeaccidentsoutside
Stabilitycalculations...........................137 Thestabilitybook................................ 138 Training/operations............................ 138Designandcertification......................139 Thebollardpullcertificate ................ 139 Testingoftheemergencyreleasesystem .................................... 139
Certificationofwinchoperator ..........139Directemergencyexitfromtheengine-room.........................................139Equipment............................................139Rescuefloats........................................139Survivalsuits........................................140Emergencytransponder.....................140 Voyagerecorder..................................140Requirementsforthecompany’ssafetymanagement ............................140 Vessel-specificanchor-handling
procedure.............................................140Overlap/familiarisation/handover....141Identifyneedforqualifications..........141POBlistsondepartureoffshore ........141Planningoftherigmove....................141Executionoftherigmove..................141Start-upmeetingandcommunication...................................142
Tandemoperations.............................142 Attentionzonesforrunning-outofanchors............................................142
Norwegianterritory............................142
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13NOU2008:8
Thelossofthe“BourbonDolphin”on12April2007 Chapter1
Chapter 1Summary
InthisSummarytheCommissionprovidesabriefaccountof theaccidentitselfandasummary reproductionofkeyconclusionsofthereport.Fortherecord,theCommissionwouldnotethatcertainnuanceswillbemissinginsuchasummary.
1.1 The Accident
The“BourbonDolphin”wasdeliveredtothecompany,BourbonOffshoreNorway,atthebeginningofOctober2006bytheshipyardUlsteinGroupinUlsteinvik,MøreogRomsdalcounty.Thevessel wasdesignatedDP2AnchorHandlingTugSupply Vessel,builtandequippedtoperformanchorhandling,towingandsupplyoperationsindeepwater.Shehadagrosstonnageof2,974tonnes,was75.2metreslongand17metreswide.Thevesselhada
continuousbollardpullof180tonnesandatensiononthemainwinchof400tonnes.Thevessel wasputintooperationimmediately;uptotheaccident,shehadcompleted16assignments.
From the end of March 2007 the “BourbonDolphin” was on contract to the oil companyChevron. The contract concerned anchor-handlinginconnectionwiththemoveofthedrillingrig“TransoceanRather”ontheRosebankoilfield, westofShetland.
The ocean depth in the area concerned is1,100 metres. The rig is moored with eight anchors. The distance between the rig and themooringpositionswasaround3,000metres.Themooringlineswereabout3,500metres,ofwhichabout900metreswasof84mmchainandabout920metresof76mmchain,plus1,725metresof96mmwire.Deploymentofanchorswasdonebymeansofthevesselrunningouttherig’schain,connecting it to chain that the vessel had onboard,whereupontherigranoutwire.Theanchorthatwasfastenedtothevessel’schainwasthereafterlowereddowntotheseabedwiththe
aidofthevessel’swinchandwire.Duringthelastpartofthedeployment,anothervesselparticipatedbygrabbingholdof(grappling)thechainsoas
todistributetheweightofthemooringandrelievethestrainontherig.
Around 09:00 on Friday 12 April 2007 the“BourbonDolphin”begantorunoutchainforthelastanchor(no.2).Around14:45allthechainwasout.The“BourbonDolphin”thendriftedconsiderablyoffthemooringlineandaskedtherigfor
assistance.The“HighlandValour”wassenttoassistthe“BourbonDolphin”,butdidnotsucceedinsecuringthechain.The“BourbonDolphin”driftedeastwardstowardsthemooringofanchorno.3.Theriginstructedthevesselstoproceedwest wards,awayfromanchorno.3.Duringanattempttomanoeuvrethevesseltowardsthewest,atthesametimeasthechain’spointofattackoverthesternrollershiftedfromtheinnerstarboardtowing-pintotheouterporttowing-pin,thevesselde velopedaseriouslisttoport.Theenginesonthe
starboardsidestopped.Thevesselatfirstrightedherself,butsoonlistedagain andat17:08 rolledoveronherportside.
Thecapsizinghappenedsuddenlyandwithoutmuchwarning.Ofthoseonthebridge,onlyoneofthe first officersmanaged to get out. The crewmembers who had been in the deck area managedtogetholdoflife-jackets,climbontothevessel’ssideandjumpintotheseabeforesherolledright over. Two persons who had been in themessgot themselvesoutontodeckand intothesea.
Full alarm was immediately sounded on therigandthevesselsintheareawereatoncesettosearchingforsurvivors.HelicoptersfromtheBritish coastguard were alerted and arrived on thespotafteraboutanhour.Othervesselsinthevicinityalsoproceededtothecasualty.
The“BourbonDolphin”had acrewof14persons.Alsoonboardwasthemaster’s14-year-oldson. Seven persons were saved. The bodies ofthreepersonswerefoundinthesea,theremainingfivepersonsarestillmissing.
Thecasualtyremainedsomedaysafloat,bottom-up, until she sank onSunday 15April.The“BourbonDolphin”hassubsequentlybeenlocat
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14 NOU2008:8
Chapter1 Thelossofthe“BourbonDolphin”on12April2007
edontheseabed,wheresheislyinginanalmostuprightposition.
1.2 The structure of the report
Most chapters contain partial and main conclusionsrelatedtothemattersunderdiscussion.Thesummaryought thereforetoberead inconjunctionwiththemainpresentation.
Chapter2describestheestablishmentandappointment of the Commission, its qualificationsandtermsofreference,theworkoftheCommission of Inquiry, including the implementationofopenhearingsandthecollectionofevidence,theuseofexpertwitnesses,theaddressingofthead versarialprincipleandrequirementsas topublic
accesstodocuments.Chapter 3 presents regulatory requirements
foranchor-handlingvesselsandanchor-handlingoperations. By way of introduction, the international regulations and Norwegian legislation onmaritimesafetyareexplained.Thereafterfollowsareviewoftherequirementsforthevessels’designandequipment,safetymanagementsystem,manningandqualifications.Nextarereviewedtherequirementsforcontrol,inspectionandcertification.AnexplanationisgivenoftheBritishregula
torysystemforanchor-handlingoperationsandoftheguidelinesforthisthattheindustryorganisationshaveadoptedfortheNorth-WestEuropean Area. Finally, operational standards for the performanceofmarineoperationsandregulatoryrequirementsrelatedtothemooringsystemfortherigarereviewed.
Chapter4providesadescriptionofthecompany,BourbonOffshoreNorway.Thechapteralsodiscusses the crews during the operation, thecompany’s safety management system, certificationandaudits.
Chapter 5 gives a factual description of the vessel “Bourbon Dolphin”. Design, constructionprocessandcommissioning,thevessel’stankarrangement, engines, anchor-handling equipmentand winchsystem withemergency release functionarereviewedrelativelythoroughly.Thechapteralsodiscussesthevessel’sstabilitybookandloadcalculator.Rescueequipmentandnavigationequipmentareadditionallydealtwith.Inconclusion,thevessel’soperatinghistoryisdescribed.
Chapter6reviewstherigmovethatthe“Bour
bonDolphin”washelpingtoperform.Bywayofintroduction the Commission will describe theplayersonthecommissioningside–theoilcom
pany,therigcompanyandtheconsultancyfirm,specificationsfortherigandanoverviewofpersonnelontherigduringtheoperation.Arelativelythoroughreviewoftheplanningoftherigmoveisalsomade–thechoiceofmooringsystemand
installationmethod,requirementsforthevessels, weather criteria and risk assessments and plansforalternativesituations(contingencyplanning).
Chapter 7 presents key data for the vesselsthat were selected by the operator for the rigmove.
Chapter8providesareviewoftherigmoveuptothecapsizing,includingthecrewchangeonthe“BourbonDolphin”.
Chapter 9 presents the incidents that on 12 April2007endedwith thecapsizingofthe “Bourbon Dolphin”.Firstcomesanexplanation of the
running-outofthediagonalanchor(no.6);thenapresentationoftheattempttoassistmadebyanothervessel.Thenanaccountoftheactualaccident is given, including for the external forcesthataffectedthevesselinthedecisivephase.
Chapter 10provides, byway of introduction,anaccountofthecrew’sevacuation.Thisisfollowedbyachronologicalpresentationoftherescueoperation’sindividualphasesandimplementation,includingavailableresourcesanduseofvariousrescueaids.Thechapteralsodealswiththe
roles played by Norwegian authorities and thecompanyduringtherescueoperation.Chapter 11describes the measures taken in
anattempttosalvagethecasualty.BywayofintroductiontheCommissionprovidesalistofobser vationof thecasualty’spositions.Therefollowsapresentation of occurrences until the signing ofthesalvagecontract,ofthebodiesinvolvedandthedecisionstakenalongtheway.
In Chapter 12 the Commission undertakessummarising analyses and considers the directandindirectcausalrelationshipsandthereport’sapproachtoquestionsofresponsibility.
InChapter13theCommissionmakesitsrecommendations.
1.3 Key conclusions
A selection of key conclusions of the report isherepresented.TheorderdoesnotsayanythingabouttheirimportanceinrelationtotheaccidentandtheCommission’stermsofreference.
Keyconclusionsare:• Thevesselwasbuiltandequippedasanall-
roundvesselAHSV(AnchorHandlingSupply
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15NOU2008:8
Thelossofthe“BourbonDolphin”on12April2007 Chapter1
Vessel).Unitingthesefunctionsposesspecialchallenges.Inadditiontobollardpull,anchor-handlingdemandsthrustercapacity,powerful winches, big drums and equipment for handling chain. Supply and cargo operations
demandthebiggestpossible,andalsoflexible,cargocapacitiesbothondeckandintanks.The“BourbonDolphin”wasarelativelysmallandcompact vessel, in which all these requirementsweretobeunited.
• ThecompanyhadnopreviousexperiencewiththeA102designandoughtthereforetohaveundertakenmore critical assessments of the vessel’s characteristics, equipment and notleastoperational limitations,bothduring herconstructionandduringhersubsequentoperationsundervariousconditions.Thecompany
didnotpickuponthefactthatthevesselhadexperienced an unexpected stability-criticalincidentabouttwomonthsafterdelivery.
• Thevessel’sstability-relatedchallengeswerenot clearly communicated from shipyard tocompanyandonwardstothosewhoweretooperatethevessel.
• Undergivenloadconditionsthevesseldidnothavesufficientstabilitytohandlelateralforces. The winch’s pulling-power was over-dimensionedinrelationtowhatthevesselcouldin
realitywithstandasregardsstability.• The anchor-handling conditions prepared bythe shipyard were not realistic. Nor did theNorwegianMaritimeDirectorate’sregulatorysystem make any requirement that these beapproved.
• The ISM Code demands procedures for thekeyoperationsthatthevesselistoperform,Despitethefactthatanchor-handlingwasthe vessel’smainfunction,therewasnovessel-specificanchor-handlingprocedureforthe“BourbonDolphin”.
• The company did not follow the ISM code’srequirementthatallriskbeidentified.
• Thecompanydidnotmakesufficientrequirementsforthecrew’squalificationsfordemandingoperations.Thecrew’slackofexperience was not compensated for by the addition ofexperiencedpersonnel.
• Themasterwasgiven1½hourstofamiliarisehimselfwiththecrewandvesselandtheongoingoperation.Initssafetymanagementsystemthecompanyhasarequirementthatnewcrews
shallbefamiliarisedwith (inducted into)the vesselbeforetheycantakeuptheirdutiesonboard.Inpracticethemasterfamiliariseshim
self byoverlapping withanothermaster whoknowsthevessel,beforehehimselfisgiventhecommand.
• Neitherthecompanynortheoperatorensuredthat sufficient time was made available for
hand-overinthecrewchange.• Thevesselwasmarketedwithcontinuousbollardpullof180tonnes.Duringananchor-handling operation, in practice thrusters arealways used for manoeuvring and dynamicpositioning.Therealbollardpullisthenmaterially reduced. The company did not itselfinvestigate whether the vessel was suited totheoperation,butleftthistothemaster.
• Thecompanydidnotseetotheacquisitionofinformationaboutthecontentandscopeoftheassignmentthe“BourbonDolphin”wassetto
carryout.ThecompanydidnotitselfdoanyreviewoftheRigMoveProcedure(RMP)withaviewtoriskexposureforcrewandvessel. Thecompanywasthusnotinapositiontoofferguidance.
• TheNorwegianclassificationsocietyDetnorskeVeritas(DNV)andtheNorwegianMaritimeDirectoratewereunabletodetectthefailuresinthecompany’ssystemsthroughtheiraudits.
• Inspecifyingthevessel,theoperatordidnot
takeaccountofthefactthattherealbollardpullwouldbemateriallyreducedthroughuseofthrusters.Inpracticethe“BourbonDolphin” wasunsuitedtodealingwiththegreatforcesto whichshewasexposed.
• The mooring system and the deploymentmethodchosenweredemandingtohandleand vulnerableinrelationtoenvironmentalforces.
• PlanningoftheRMPwasincomplete.Theprocedurelackedfundamentalandconcreteriskassessments. Weather criteria were notdefinedandtheforceswerecalculatedforbetterweatherconditionsthantheychosetooperatein.Definedsafetybarrierswerelacking.It waslefttothediscretionoftherigandthevesselswhetheroperationsshouldstartorbesuspended.
• Inadvanceoftheoperationnostart-upmeeting withallinvolvedpartieswasheld.Thevesselsdid not receive sufficient information about whatcouldbeexpectedofthem,andthemastermisunderstoodthevessel’srole.
• Theproceduredemandedtheuseoftwoves
selsthathadtooperateatclosequartersindifferentphasesduringtherecoveryanddeploymentofanchors.Theincreasedriskexposure
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ofthevesselswasnotreflectedintheprocedure.
• The procedure lacked provisions for alternative measures (contingency planning), forexample in uncontrollable drifting from the
run-out line. Nor were there guidelines for whenandinwhatwaysuchalternativemeasuresshouldbeimplementedandwhatifanyriskthesewouldinvolve.
• The deployment of anchor no. 2 was commencedwithouttheconsiderabledriftingduringthedeploymentofthediagonalanchorno.6hadbeenevaluated.
• Humanerroronthepartoftherigandthevesselsduringtheperformanceoftheoperation.
• Communicationandcoordinationbetweentherigandthevesselwasdefectiveduringthelastphaseoftheoperation.
• Lackofinvolvementonthepartoftherigwhenthe“BourbonDolphin”drifted.• Therollreductiontankwasmostprobablyin
useatthetimeoftheaccident.• The inner starboard towing pin had been
depressedandthechainwaslyingagainsttheouterstarboardtowingpin.Thechaintherebyacquiredachangedangleofattack.
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Chapter 2The Commission of Inquiry and its work
2.1 Introduction
On27April2007theMinistryofJusticedecided,ontheauthorityofSection485oftheMaritimeAct,toappointaspecialcommissionofinquiryintothelossofthe“BourbonDolphin”on12April2007.
The Commission’s composition was as follows:1. CourtofAppealsJudgeIngerLyng,Chair2. SpecialistengineerGuroHøyaasLøken3. GeneralManagerGisleFiksdal4. MarineCoordinatorDagAndreassen5. PoliceProsecutorYngveSkovly
The secretary to the Commission was TerjeHernesPettersen,SeniorAdvisorintheMinistryofTradeandIndustry.
2.2 More on the members of theCommission of Inquiry
TheCommissionconsidersitappropriatetogivetheeducationandprofessionalbackgroundofthemembers.
Inger Lyng
Yearofbirth1947Cand. jur.qualifyingexaminationinlaw1976SeniorExecutiveofficerintheMinistryofJustice AssistantJudge JuniorPoliceProsecutorLegalAdvisorMunicipalAttorneyofTromsøChairmanoftheCountyAppealTribunal JudgeinHålogalandCourtofAppealsfrom1997
Guro Høyaas Løken
Yearofbirth1972GraduateinNavalArchitecturefromtheNor wegianUniversity ofScienceand Technology(NTNU),1996–Specialisationinhydrodynamics/marinestructures.
Aker Marine Contractors AS Naval Architect1997–1998,CSOAkerEngineeringInc./Technip Inc. Houston, Senior Specialist, 1998 –2002,AkerMarineContractorsInc.Houston,Principal Naval Architect 2002 – 2005, AkerMarineContractorsAS2005,SpecialistEngineer–Planningandexecutionofmarineoperations,platformdesign,mooringdesign,movementanalyses,modeltestcorrelationsandrigupgrade studies. Course instructor, Marine WorksManagerandEngineeringManager.
Hasgivenanumberof lectures/papersfocusingonmooringdesignindeepwater.
Gisle Arnold Hansen Fiksdal
Yearofbirth1961GraduatedinengineeringfromtheNorwegianInstituteofTechnology(theprecursorofthepresentNorwegianUniversityofScienceand Technology)Trondheim1984,andinmanagementfromtheNorwegianSchoolofManagement(BI)1990.MARINTEK,researcher,1986-2001,LodicAS,GeneralManager,2001Development/maintenance of software forhydrostaticsandstability–ShipshapePreparationofstabilitybooksforvarioustypesofshipDevelopmentoftheloadcalculatorShipLoadandLodic,foruseonboardvariouskindsof vesselStability studies for “The Commission ofInquiryintothelossofWestern”
Developmentofdecision-makingsupportsystems for ships in a damaged state (EUprojects)
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Assistance in salvage operation/investigationafterthe“Rocknes”accident.
Dag Andreassen
Yearofbirth1946Ship’smasterexamination1981DNVIncidentInvestigationTrainingExxonMobilRiskAnalysisTrainingLevelIIMarine specialist ExxonMobil 1987–2008:Planning,theimplementationofmobileinstallations,vesselinspections1973–1987:Practicalexperiencefromoffshoreoperations.Ship’smasterfrom1981.
Yngve Skovly
Yearofbirth1962Cand. jur qualifyingexaminationinlaw1988Policeattorney,Hardanger AssistantJudgeinSunnmøre Assistant Chief of Police/Police ProsecutorSunnmøre Advisor, crisis management aid project“Styrkebrønn”(“WellofStrength”),Georgia
Terje Hernes Pettersen
Yearofbirth1968Cand. jur.qualifyingexaminationinlaw1996MasterofLaw1997Project Manager, The Norwegian MaritimeDirectorateMember,MaritimeSafetyActCommittee Advisor/SeniorAdvisor,TheNorwegianMaritimeDirectorateSeniorAdvisor,MinistryofTradeandIndustry
2.3 The Commission of Inquiry’s
competence and terms of reference
TheCommissionofInquiry’smissionisgovernedby the Regulations No. 7 of 28 November 1980pertaining to commissions of inquiry under theMaritimeAct.
The mission is defined in the Commission’stermsofreference,whicharewordedasfollows:
“TheCommission ofInquiry shallundertaketheinvestigationsitfindsnecessarytoclarifythecourseofeventsandcausalfactors,andreportonfactorsofsignificance forpreventingsuchaccidentsinfuture.Thisincludesthecoordinationbetweentheshipandtherig,opera
tionoftheshipandfactorsrelatedtotheship’sdesignandcertification.
TheCommissionofInquiryshall alsopro vide an assessment of the attempted salvageoperation during which the ship sank. TheCommissionshallfurtherconsiderfactualcircumstancesthatcanbeenvisagedasjustifyingcriminalliabilityforindividualsorenterprisesorotherliabilityinconnectionwiththeaccident. The deadline for the Commission’s reportis1February2008.”
Thereportdeadlinewaslaterextendedto1April2008.
TheaccidenthappenedintheUKSectoroftheNorthSeaandinvolved,inadditiontotheNorwegian-registered vessel, a British oil company, adrillrig owned by a company registered in the
Cayman Islands, a British consultancy firm andseveral foreign-registered vessels with theircrews.
The Commission has endeavoured to find areasonable balance between the imperative ofconsidering all the questions that the accidentprovidesoccasiontoevaluate,andtheimperativeofmakingthereportasquicklyasproperandpossible. Regarding the questions the Commissionhasraised,ithasspentthetimeitthoughtnecessaryforathoroughanalysisandaddressingofthe
interestsofaffectedparties.ItispartoftheCommission’stermsofreferencethatitshouldconsiderfactualcircumstancesthatcanbeenvisagedasjustifyingcriminalliabilityforindividualsorenterprisesorotherliabilityinconnectionwiththeaccident.
ItiswidelyknownthattheNorwegianprosecution authorities, under the leadership of thePublic Prosecutor of Møre og Romsdal County,havelaunchedaninvestigationinthecase.InvestigationsareinprogressalsoontheBritishside,undertheaegisoftheHealthandSafetyExecutive(Aberdeen).NeithertheNorwegiannortheBritishinvestigationshavebeenconcluded.
TheCommission isnotacourt.TheCommissionunderstandsitstermsofreferenceasmeaningthatthepresentationofthefactsofthecaseisasufficientpresentationofrelevantcircumstances.Anyassessmentofthefactsinrelationtocriminallawwithaviewtocriminalsanctionsorinrelationtorulesforadministrativemeasuresorreactionsincivillawisamatterfortheprosecutionauthority, otherauthorities, the parties and any
one else affected to decide upon, if necessarythroughcourtproceedings.
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The Commissionhas,however, considered itappropriateinsomecontextstoevaluateandcharacterisethebehaviourofindividualsandinstitutionsonthebasisofprovenfacts.TheCommissionhasnottherebytakenapositiononwhether
criminallaworothersanction-bearingruleshaveactuallybeencontravened. Therescueoperation,whichwas ledbyBrit
ish authorities, was not a part of the Commission’stermsofreferenceandhasnotbeentheob jectoffurtherinvestigation.TheCommissionhas,however,considereditrighttoprovideasummarypresentationoftherescueworkaswell.
2.4 The work of the Commission ofInquiry
The Commission of Inquiry has held regular workingmeetingsever yotherweeksincetheappointment,alltogether20workingmeetingswithatotalof57meetingdays.TheCommissionhasheldfiveopenhearingsforreceiptoftestimonyfrom involvedparties, confer the discussion belowinSection2.5.
The Commission has collectively, or via indi vidual members, undertaken several site visits. The“BourbonDolphin”wasthefirstvessel tobe
builttoanUlsteinA102design.TheCommission wasthereforeunabletomakeasitevisittoasimilarvessel.Soastoreceiveaquickgeneralintroduction to the methodology of anchor-handling,theCommissionvisitedtheanchor-handlingvessel“NormandMaster”belongingtoSolstadRederi,whileshewasberthedatStavanger.
CommissionMemberGisleFiksdalhasvisitedtheshipyard,UlsteinVerft.CommissionMemberDagAndreassenhas,togetherwithCaptainFrankReiersen,undertakenareviewandtestingofrescueequipmentcorrespondingtothatwhichwasonboardthe“BourbonDolphin”.
TheCommissionchosenottovisitthecompany,BourbonOffshore.TheCommissionheldbriefinginterviewswithrepresentativesofthecompanyimmediatelyaftertheappointment.Thecompany’srepresentativesweresummonedtoanopenhearingonthesamebasisasotherinformants.
TheCommissionhasheldmeetingswith thenextofkinandtheirattorney.TheCommission’smembers held several telephone conversationsand handled otherapproaches from the next of
kin. TheCommissionhasotherwiseheldmeetings
withtheNorwegianMaritimeDirectorate,thePe
troleumSafetyAuthority,DetnorskeVeritas,theinsurers,theprosecutionauthorityandrepresentativesoftheBritishHealthandSafetyExecutivesoastoreceivetheirinput.
TheCommissionhasbeengivenaROV(min
isub)inspectionvideofilmtoreview,takenofthe wreckat1,100metresdepthon8December2007. TheCommissionhasreceivedanumberofin
puts from interest organisations, the media andthepublic.
The Commission’s secretariat has been inOslo.TheSecretarytotheCommissionhasbeenrelievedofhalfofhispermanentpostintheMinistryofTradeandIndustry.Itwasnecessarytoreinforcethesecretariatwithhiredconsultants.TheChairoftheCommissionwasrelievedofallherother duties. The remaining members have
workedonanhourlybasis. An English version of the Commission’s re
portalsoexists.TheCommissionhasnotbeenin volvedinthetranslation,anddoesnotguaranteethisversion.
2.5 Collection of the evidence
Themaritimeinquiryfollowing theaccidentwasheldinSunnmøreDistrictCourton25April2007.
TheCommissionhasheldfiveopenhearingsasasupplementtothismaritimeinquiry.InJune2007theCommissionheardtestimonyfromthecrewsof the “BourbonDolphin”, the company’s representativesand the mastersofthe“OlympicHercules”andthe“VidarViking”.TheCommissionalso held conversions with the next of kin in aclosed forum. In August 2007 the Commissionquestionedthesolesurvivingofficerofthe“Bourbon Dolphin”, the vessel’s two regular mastersand the first engineering officer from the shiftthatwasnotonboardduringtheaccident.Attheend of August the Commission questioned Detnorske Veritas’ local representative in Aberdeenand fourofficersfromthe “Highland Valour”. InSeptember2007theCommissionheardtestimonyfromrepresentativesofChevron,the“TransoceanRather”andTrident,inall11persons,whohadbeenresponsiblefortheplanningandtheimplementationoftherigmoveoperationandthesubsequentrescueandsalvageoperation.InOctober2007 the Commission questioned three personsfrom Ulstein Verft and three persons from the
NorwegianMaritimeDirectorate. AlltogethertheCommissionheard testimony
from38persons.Everyonecalledinforquestion
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Chapter 3Regulatory requirements for anchor-handling vessels and
anchor-handling operations
3.1 Introduction
Safetyatseaisgovernedbyaveryextensiveregulatory system. This chapter provides a para
mountdescriptionof the rules that apply toanchor-handlingvesselsandanchor-handlingoperations.Moredetailedassessmentsofwhethertheregulatoryrequirementsweremetwillfollowinthe subsequent chapters, whereas Chapter 13containsrecommendationsforchangesintheregulatorysystem.
Bywayofintroductiontothechapter,anover view is provided of the international regulatorysystem and Norwegian legislation on maritimesafety.Sections3.2to3.4providedescriptionsof
requirementsdirectedatships,whileSection3.5describesthesystemofshipsupervision.Section3.6providesabriefaccountoftheBrit
ishregulatorysysteminrelationtoanchor-handlingoperations.ThistextisbasedonthelegalopinionofResearchFellowHanneSofieLogstein,seeAnnex1Part7.Section3.7discussesguidelinesforthesafemanagementofoffshoresupplyand anchor-handling operations (NWEA); thistext isalsobasedonLogstein’s opinion.Section3.8 provides a brief description of operationalstandardsforperformanceofmarineoperations. Theserules aredirectedattheoperatorandrig.Inconclusion,Section3.9providesadescriptionoftherequirementsforthemooringsystemoftherig“TransoceanRather”.
3.1.1 The international maritime safetyregulations
A numberof international conventions lay downrequirementsforinteraliashipdesignandequipment, for those working on board ship, for the
protectionoftheenvironmentandfortheworkingandlivingconditionsofseafarers.TheLawoftheSea Treaty contains general ruleson the rights
anddutiesoftheflagstateandthecoastalstate,and lays the primary responsibility for supervisionofshipsontheflagstate.MostofthemaritimeconventionshavebeenadoptedbytheUN’sInternationalMaritimeOrganisation(IMO).The
organisation was created in1948andiscommitted toenhancing safety atsea, preventingpollution of the marine environment, and anti-terrormeasuresinmaritimeactivity.TheIMOhas167member-states.BelowfollowsalistofimportantIMOconventions:• SOLAS–TheSafetyofLifeatSeaConvention,
1974• MARPOL73/78–TheInternationalConven
tionforthePreventionofPollutionfromShips,1973/78
• STCW – The Convention on Standards of Training, CertificationandWatch-keepingforSeafarers,1978
• TheLoadLinesConvention,1966• COLREG – The Convention on International
Regulations for Preventing Collisions atSea,1972
The IMO conventions contain so-called “minimumstandards”.Thereistherebynothingtopre vent the flag states from promulgating stricterprovisions, but it is established practice for theflag states to follow the IMO conventions, interaliaforreasonsofcompetition.TheinternationalConventiononSafetyofHumanLifeatSea,SOLAS,isthemostimportantofalltheIMOconventions.ThemainpurposeofSOLASistostipulateminimum requirements for design, equipmentand operation ofships, thereby enhancing maritimesafety.Theflagstateisresponsibleforensuringthatshipssailingunderitsflagsatisfytherequirements of the convention, confer Article II. The convention fixes the number of certificates
theshipsmusthaveasevidenceoftheirhavingsatisfied the requirements. Via the conventions,the IMO has also adopted a number of codes,
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whichusuallycontain technicalamplifyingdetailontheconventions.As examplesmightbementioned the Intact Stability Code, the LSA Code(rescueequipment),theISPSCodeandtheISMCode,conferSection3.3.
ManyoftherequirementsoftheIMO’sregulatorysystemaregenerallydraftedandapplyinprincipletoallships.Roughlyspeaking,adistinction is made between requirements directed atcargo ships, passenger ships and fishing-boats. Anchor-handling vessels fall under the categoryofcargoships.Withintheregulatorysystemthatapplies to cargo ships, certain specific requirements are made for certain categories of cargoships, such as oil tankers, contingency vessels,towingvesselsetc.Thestabilityrequirementsforsupplyvesselsarealsoappliedtoanchor-handling
vessels.ThegreatmajorityoftherequirementsintheIMO’sregulatorysystemapplyonlytoshipsthatareundertakinganinternationalvoyage,thatis to say, a voyage between ports in differentstates.Fortrafficthatisexclusivelynational,thelegislativejurisdictionistoalargeextentlefttothe flag state. For mobile installations the IMOhasonlytoasmallextentissuedbindingnorms,but the organisation has adopted the so-calledMODU Code (Mobile Offshore Drilling UnitCode)asanadvisorystandard.
3.1.2 Norwegian maritime safety legislation
The conventions are currently implemented byauthorityoftheActNo.9of16February2007onmaritimesafety(theMaritimeSafetyAct).Mostof the statutory regulations are promulgatedbytheNorwegianMaritimeDirectorate.Thestatutoryregulationsystemhastoalargeextentimplementedinternationalstandardsbymeansofreferences(incorporation).Atthetimeoftheaccidentof12April2007itwastheActNo.7of9June1903on State Control of the Seaworthiness of Shipsetc.(theSeaworthinessAct)thatwasinforce.
The main duty-holders under the SeaworthinessActweretheship’smasters,conferSection106firstparagraph.Theprovisionlaiddownthatthe responsibility for conforming to provisionsmadetosecuretheship’sseaworthinessortoaddressthesafetyorwelfareofpersonsonboardrests upon the ship’s master, unless otherwiseconsequentontherelevantActorprovision.
Section106secondparagraphoftheSeawor
thinessActprescribeddutiesforthecompanyoranyoneactingonbehalfofthecompany.Thepro visionwas incorporatedbyAmendmentNo.70of
2August1991asafollow-upofthe“ScandinavianStar”disaster.Itmandatedthecompanytoestablishroutinesthatensuredthatashipwasinsoundandregulationconditionandthatshewasinspectedinaccordancewiththerules.
Also Section 106 third paragraph made thecompanyaduty-holder.TheprovisionwasaddedbyAmendmentNo.67of10June1977inordertoprovide a clearer formulation of the lines of responsibilitybetweencompanyandship’smasterregarding safety matters. It lays down that thecompanymustnotunlawfullycauseorbeaccessorytocausinganunseaworthyshiptoputtoseaortotheshipbeingusedincontraventionofpublicpermits. The travaux préparatoires maintainedthattheprovisionwasnotintendedtochangethecurrentstateofthelaw,underwhichtheship’s
masterhadtheprimeresponsibilityonboardfortheoperationoftheship.Norwasittheintentiontoextendthecompany’sresponsibility.TheSea worthinessActalsocontainedsomespecialprovisionsthatimposeddutiesonpersonsotherthantheship’smasterandthecompany,seeforexampleSection11secondparagraph,whichforshipsbeingbuiltinNorwayimposedontheshipyardadutytonotifythesupervisoryauthority.
TheSeaworthinessActwasrepealedon1July2007 and replaced by the Maritime Safety Act.
The new law has toned down the duties of theship’smasterandtoamuchgreaterextentmakesitclearthatitisthecompanythathastheparamount responsibility for the safety of the ship,conferSection6.
3.2 Requirements for the vessel’s designand equipment
Thekeyprovisionsforshipdesignaretobefoundin SOLAS Chapter II-1, which makes requirementsforthevessel’shull,strengthandstability, whereas Chapter II-2 deals with fire safety. Theflag states have issued supplementary requirementstoSOLAS.Moreover,SOLASChapterIII,IV and V contain requirements for respectivelyrescueequipment,radiocommunicationandnavigationequipment.Detailedrequirementsforloadline and freeboard are to be found in the LoadLinesConvention.
Statutory Regulations No. 695 of 15September1992(theBuildingRegulations),laiddownby
theNorwegianMaritimeDirectorate,arethekeyimplementingregulationsforChapterII-1ofSOLASandtheLoadLinesConvention.TheRegula
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tions contain some special requirements for anchor-handlingvessels,forexamplefortowingandanchor-handlingequipmentinSection48,whichlays down rules for winch, wire and chain-stoppers,spoolingapparatus,towing-pinsandcrucifix.
The Regulations contain no specific requirementsforanchor-handlingoperations,asregardsneither stability requirementsnor set-up of loadconditions.Stabilitywise,ananchor-handlingvesselisregardedasanordinarysupplyship,conferSection43firstparagraph.
Section43secondparagraphcontainsspecificrequirementsforthestabilityofshipsengagedintowing.Theserequirementsaddressthefactthatthevesselcanbeexposedtoalistmomentinconsequence of the tow operation (which the ordinary requirements for supply ships do not do).
Under the Norwegian Maritime Directorate’spractice,anchor-handlingoperationsarenotevaluatedinrelationtotheserequirementsinstabilityapproval.
Section 43 third paragraph makes requirementsforloadconditionsthataretobesubmittedforapproval (rule conditions). No requirementsaremadeforloadconditionsforanchor-handlingoperationsbeingpreparedandconsideredinrelationtostability.Itisuptothecompanyandtheshipyard/designerto include suchconditions in
the stability book (example conditions). Theguidelines for stability in IMO Resolution A.469(XII)arenotdirectlyimplementedintheNorwegian regulatory system foranchor-handling vessels. The resolution recommends, indirectlythroughSection2.4.2asanalternativeifSection2.4.1isnotcompliedwith,thatstabilityoughttobecalculatedforthe“worstanticipatedoperatingconditions”.ThisisreflectedintheBuildingRegulationsSection12firstparagraph,whereaworstexpected operating condition, confer the resolution,willhavebeincludedasoneof“allrelevantloadconditions” inwhichthevesselis designedandintendedtooperate.
Theloadconditions,includingtheanchor-handling conditions, must be representative of therelevantoperations.Iftheloadconditionforanchor-handlingdeviatesfromwhatmustbeincludedinthestabilitybook,thecrewmustperformtheirownstabilitycalculationswiththetoolsavailableonboardforthis.
The Norwegian Maritime Directorate doesnot require the stability book to contain special
loadconditionsforanchor-handling.Iftheseareneverthelesscoveredbythebook,itischeckedonlythatthesubmittedconditionsforanchor-han
dlingmeet the stability requirementsofSection43 first paragraph. No evaluation is made of to what extent the conditions are applicable to theoperationinquestion,providedthattheynotcontainobviouserrors.Theconditionsarethusnot
subjecttotheDirectorate’sapproval.Pursuanttothe Building Regulations Section 8, 13th paragraph,stabilityinformationshallbepreparedthatinarapidandsimplemannerenablestheship’smastertoenjoypreciseguidanceabouttheship’strim and stability under different sailing conditions.
TheBuildingRegulationsSection15sixthparagraph demand that when vessels are equipped withrollreductiontank(s),accountshallbetakenofthestabilityreductioncausedbytheiruse.Itisalsodemandedofthecompanythatinstructions
bepreparedfortheuseofthetank(s),plus loadconditionsthatcorrespondwiththeinstructions,ifthetanksforstability-relatedreasonscannotbeusedinallloadconditions.
RequirementsforrescueequipmentforcargoshipsfollowfromStatutoryRegulationsNo.1856of17December2004 (the Rescue Regulations). The Regulations implement the SOLAS ChapterIIIandLSA(LifeSavingAppliance)CodeinNor wegianlawasregardscargoships.Theyincludeprovisions onrescue vessels and hydrostatic re
lease mechanisms for rescue floats, confer Sections8and9.Annex1totheRegulationscontainsfurtherdetailedrequirementsforrescuevessels:amongotherthingsarescuefloatshallfloatfree,and,ifitisinflatable,shallinflateautomaticallyiftheshipsinks.Onthe“BourbonDolphin”sixinflatablerescuefloatshadbeeninstalled.
SOLASChapterIVandVisimplementedbyStatutory Regulations No. 701 of 15 September1992onnavigationalaids(theNavigationRegulations)andStatutoryRegulationsNo.1855of17December2004onradiocommunicationoncargoships (the Radio Regulations). The Commissionhasnotfounditnecessarytogofurtherintomattersconcerningnavigationandtheradiocommunicationsystemofthe“BourbonDolphin”,andnomoredetaileddescription of this regulatorysystemisthereforegiven.
3.3 Requirements for the safetymanagement system
“TheInternationalManagementCodefortheSafeOperationofShipsandPollutionPrevention”(theISMCode),wasapprovedbytheIMOon4No
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vember1993viaResolutionA.741(18).TheCodeisanchoredinSOLASChapterIX.TheISMCodemakes requirements for a Safety ManagementSystem(SMS)onshipsandforcompanies.IntroductionoftheISMCodemadethecompany’sre
sponsibilityforthesafetyoftheshipclearer. Thebackgroundto theCodewasadesire todevelop a better safety culture in the maritimesector.Itwasdesiredtoenhancesafetyatseabyfocusingonsafetyforthoseinvolvedonboardandonshore,amongotherthingsviaroutinesforqualityassurance.Investigationsfollowingmajorshippingaccidentsinthe1980sandthebeginningofthe 1990s demonstrated serious administrativefailures,bothonboardshipandinthecompanies’shoresideorganisations.TheISMCodehasbeencharacterised as innovative in maritime safety
work,sinceforthefirsttimeitaimedataholisticapproachthatlookedattheshipandherownersandtheinteractionbetweenhumanbeings,technology and organisation. The preamble to theCodeproclaimsinteraliathatitisbasedongeneralprinciplesandobjectives,sincenotwocompaniesarethesameandshipsoperateunderdifferentconditions.
TheobjectoftheISMCodeistopromotesafetyatsea,preventpersonalinjuryorlossofhumanlife,avoiddamagetotheenvironment,particular
lythemarineenvironment,andtoproperty,confertheCode’sRule1Section2.1.TheISMCode’sRule1Section 2.2.2demands that the company, via the safety management system, introduce aprotectionagainstallidentifiedrisks.Therisksto whichvessel andpersonnelcanbeexposedshalltherefore be charted and controlled within thecompany’s organisation. More detailed requirements for risk assessments, including safe jobanalyses, are contained in Statutory RegulationNo. 8 of 1 January 2005 (the Working Environment Regulations). This has, however, a morespecificfocusonhazardsthatmayarisefortheindividualemployeeonboardduringtheperformanceofworkoperations.
ThecoreoftheISMCodeisRule1Section4,regardingfunctionalrequirementsofsafetymanagementsystems.It islaiddownthatallcompaniesshalldevelop,implementandmaintainasafetymanagementsystemthatincludesthefollowingfunctional requirements: a policy for safety andenvironmentalprotection,instructionsandprocedurestoensuresafeoperationsandprotectionof
theenvironmentinlinewithinternationallawandtheflagstate’slegislation,definedauthoritylevelsand communication links between and among
personnelonshoreandonboard,proceduresforreporting of accidents and non-conformances withtheISMCode,proceduresforpreparationforandreactionofemergencies,andproceduresforinternalauditingandmanagementreview.
Thesubsequentprovisionsof theCodeamplifyandspecifywhatliesintheindividualfunctionalrequirements.OfthesemaybementionedRule2,that the companypreparea“safetyand environmental policy” that is to be implemented andmaintainedonalllevelsoftheorganisation,bothonboardandonshore.Rule4,ontheDesignatedPersonAshore,mayalsobementioned;inordertomaintainsafeoperationoftheshipandtoensurecontactbetweenthecompanyandthoseonboard, every company shall designate one ormore persons onshore, and theseshall have di
rectcontactwiththetoplevelofmanagement. AnotherimportantsectionoftheISMCodeis
Rule6Section5,whichdemandsthatthecompanyidentifytraininglevelsinsupportofthesafetymanagementsystem.Thisentailsarequirementthatthecompanyevaluatewhatqualificationsarenecessaryforthevessel’spersonnelinrelationtothe activity/operations to be executed over andabove the minimum requirements in the STCWConvention.Whereasformanyfunctionsitwillbesufficienttopossessqualificationspursuanttothe
requirementsoftheSTCWConvention,executionofcertainmaritimeoperationswilldemandanextendedexpertiseiftheworkistobedoneinasafemanner.
ItfollowsfromtheCodethat thesafetymanagement systems shallbe documentable, conferRule11,andbeverifiedandreviewed,conferRule12.Theshipsshallalsobeoperatedbyacompanythatiscertifiedwitha“DocumentofCompliance”,i.e.withacertificateofapproval,conferRule13Section 1. The ships shall be equipped with a“SafetyManagementCertificate”,conferRule13Section7.
The prime responsibility for safety lies withthecompany,conferRule3.Rule1Section1.2definesthecompanyastheship’sowneroranyotherorganisationorperson,forexampleashippingcompany or turnkey charterer who has takenover responsibility for the operation of the shipfromthecompanyandwhohasontakeoveroftheresponsibility consented to take over all dutiesand all responsibility imposed on him by theCode. For cargo ships the ISM Code is imple
mentedinStatutoryRegulationsNo.822of6August1996onsafetymanagementsystemsforcar
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goships.Foroffshorevesselsover500tonnestheCodeenteredintoforceon1July2002.
Requirementsforsafetymanagementsystemsare described only briefly in the Seaworthiness Act,butintheMaritimeSafetyActthishasbeen
given a central significance. The amending billProposition No. 87 to the Odelsting (2005-2006)onMaritimeSafetyemphasisedtheimportanceofsafetymanagementsystems,andtheMinistryof TradeandIndustrystatedinthatconnection:
“Thesignificanceofthefactthatthesafetyandenvironmentalworkinthecompaniesisestablished in a structured, systematic and documentablemanner,cannotbeover-emphasised.Itiscrucialthattheindividualcompanyformulatesclearobjectivesforthesafetyandenvironmentalworkandapolicyforhowtheobjectives
aretobeattainedbythecompany.TheMinistry would also emphasise the importance ofthe company’s top management prioritisingand ensuring that both the company’s safetymanagementsystemandtheindividualshipsofthecompany,functioningasdesignedandbeingcontinuouslyimproved.Withoutaclearprioritisationandfollow-uponthepartofcompanymanagement,itwillbedifficulttoachievethefulleffectofhavingasafetymanagementsystem.”
TheISMCode’smainintentionsareenshrinedintheMaritimeSafetyActSection7firstparagraph:
“Thecompanyshallseetotheestablishment,implementationandfurtherdevelopmentofadocumentable and verifiable safety management system in the company’s organisationandontheindividualships,soastochartandcontrol risksand ensure compliance with requirementslaiddowninorpursuanttotheActorinthesafetymanagementsystemitself.Thesafety management system’s content, scopeand documentation shall be adapted to the
needsof thecompanyand theactivityitconducts.”
3.4 Requirements for manning andqualifications
SOLAS Chapter V Rule 14 demands that a shiphavesufficientmanning.Amplifyingmanningrequirements are made in IMO Resolution A 890(21),whichisappliedbyNorwayandisemployed
in the Statutory Regulations of 17 March 1987
(theManningRegulations).ItistheNorwegianMaritime Directorate that determines the manningrequirementsfortheindividualvesselviaissueofamanningschedule,whichisakindofcertificate.ItfollowsfromtheRegulationsthatcargo
shipswithagrosstonnageover50shallhavestipulated manning. The requirements made bytheDirectorateareaminimummanning(safetymanning)andthecompanymustitselfdecidewhetheritisnecessarytoincreasethemanningfurther.
TheInternationalConventiononStandardsof Training,CertificatesandWatch-keepingforSeafarers (the STCW Convention of 1978) makesqualificationrequirementsforpersonnelonships. TheconventionisimplementedinStatutoryRegulationsNo.687of9May2003(theQualificationRequirements). At the time of the accident the
regulationswereauthorisedbytheActNo.42of5 June 1981 on Certification of Personnel on Nor wegianShips(theCertificationAct),whichwasapureenablingact.AmongotherthingstheCon ventionandtheRegulationsmakequalificationrequirementsforpersonnelonthebridgeandintheengine-room, and various other functions onboard.Therequirementsarebyandlargegeneral,andtoasmalldegreevessel-specific.Forpersonnelonanchor-handlingvessels,nospecialrequirementsaremadeoverandabovethegeneral
minimumrequirements. The Qualification Requirements Section 1-3secondparagraphd)makesrequirementsforfamiliarisation on (induction into) a new vessel whenthecrewreportsfordutyonaship,andlaysdown that the company and the ship’s mastershallensure:
“thatseafarers,whentheyaresettoserveonboardtheship,aremadeacquaintedwiththeir variousdutiesandwith alltheship’sarrangementsandinstallations,allequipmentandall
proceduresandspecialaspectsoftheshipthatareofrelevancetotheirduties,whetherroutinelyorinemergencies;and…”
Amongotherthings,theActNo.50of3June1977onWorkingHoursandRestTimeonShipsmaderequirementsfor77hoursresttimeaweekand11 hours rest time a day for those working onboardship.TheActwasrepealedwhentheMaritimeSafetyActenteredintoforce,andthemostimportantmaterialrequirementshavebeenincorporatedintoSections23and24.
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pervisoryauthority,forexampleclassificationsocietiesorapprovedenterprises,performtheirdelegateddutiesinasatisfactorymanner.Theclassification societies may have received delegatedassignmentsto,forexample,controldrawingsof
newbuildingsandrebuildings,andsafetymanagementsystems(ISM)onboardandinthecompany.Inprincipletheclassificationsocietiescanperform the same control as the Norwegian Maritime Directorate, provided that they havereceived delegated authority for it. In Norway,portstatecontrolisnotdelegatedtoclassificationsocieties.
3.5.3.3 More on control of vessels and mobile
installations
ThecontrolresponsibilityassignedtotheNorwegianMaritimeDirectoratecoversallcategoriesof vesseloveracertain size andallmobile installations. The approval and control work is carriedoutaslongastheentityisflying theNorwegianflag.Iftheworkhasbeendelegatedtotheclassificationsociety,thelatterwillperformalltheapprovalandcontrolwork.ThisisthesituationfortheNISfleet.ForNOR,ontheotherhand,mostoftheworkisdonebytheNorwegianMaritimeDirectorate itself. The individual phases of the
controlsystemareasfollows:
Building notification
Assoonasacontractforconstructionorrebuildingofavesselhasbeensigned,itshallbenotifiedtotheNorwegianMaritimeDirectorate.ThiswasstatedintheSeaworthinessActSection11.
Approval of the design
Drawingsare thensubmitted for approvalof design, control of calculations and approval of arrangement,stabilitybooketc.,confertheBuildingRegulationsSection8.
Construction supervision/initial inspection
Beforeshipsormobileinstallationsubjecttocontrolareputintoservice,itshallbecontrolledthatthe entity was built and equipped in conformity withtheapproveddrawings.Thisworkisdoneatthe constructing shipyard and with subcontrac
torsthroughouttheconstructionperiod.TheDirectorateshallamongotherthingsbepresentandapprovetheheel(roll)test.
Certification
When,attheendoftheconstructionperiod,ithasbeendeterminedthatthevesselorinstallationsatisfies the requirements laid down in legislation,
regulationsandinternationalconventionsapplicable toNorwegianentities,themandatorycertificatesareissued.TheNorwegianMaritimeDirectorate then stipulates the requirements for thecrew’squalificationsforallshipssubjecttocontrol and the minimum manning on passengerships,cargoshipsandmobileinstallations.
Periodic inspection
Theshipisinspectedregularly,andonthisbasisthecertificatesarerenewed.Ingoodtimebefore
theexpiryofthecertificateperiod(nolaterthan14 days before), the company is obliged to requestinspectionforrenewalofthecertificate.
Intermediate inspection and annual inspections
Formostcertificateswithalongperiodofvalidity,intermediateinspectionsoftheshiparemandatory,andusuallyalsoannualinspectionsinordertoascertainwhetherthemandatorytechnicalstandardisbeingmaintainedinthecertificateperiod.
Formostcertificates,itisusualfortheintermediateinspectiontotakeplaceinthecourseofthethirdyear.
ISM audits
Companies that operate cargo ships in internationaltraffic,passengershipsandmobileinstallationsaremandatedtohaveasafetymanagementsystemundertheISMCode.Theauthoritiesconfirm, through issuance of certificates, that thesafetymanagementsystemsatisfiesthemainrequirementsoftheISMCode;andtheyperformsystem audits both of company offices and onboard the individual vessel/installation, soas tomakesurethatthesystemsareactuallyusedandfunctionasintended.
Surprise inspections
Inadditiontotheperiodicinspectionsthatfollowdirectly from the regulatorysystem, surpriseinspectionsonboardmaybeperformed.Thesur
priseinspectionscoverfishing-boatsandpassengerships,plusdelegatedandnon-delegatedcargoshipsinNORandNIS.Inadditiontheclassifica
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tionsocietiesaremandatedtoperform10% surprisesupervisionofthatportionoftheNISfleetthattheyhavebeendelegated.
Port State Control
Pursuant to the Paris Memorandum of Understanding(MOU)andEUdirective95/21assubsequentlyamended,Norwayisobligedtocontrolatleast 25% of individual foreign ships that call inNorwegianports.Inprinciplethecontrolconsistsof ensuring that the ship has valid internationalcertificates,butamoredetailedinspectionmaybeperformedifthereisasuspicionthatashipdoesnotsatisfytheinternationalregulatorysystem.
Other kinds of supervision The Norwegian Maritime Directorate also performssupervisioninconnectionwiththeissuanceofsailingpermits,towingpermits,movingcertificates,measurementcertificates,proofofidentityandcertificatesoninsuranceagainstliabilityforoilspilldamage.Vesselsareinadditioninspectedif they have suffered accident or damage. TheNorwegian Maritime Directorate also conductssupervision of equipment suppliers’ service stationsforinflatablerescueequipment(suchequip
mentshallbecontrolledbyapprovedservicestationsatregularintervals).
3.5.3.4 The Norwegian Maritime Directorate’s
control of classification societies and
approved enterprises
As mentioned in Section 3.5.3.2, the NorwegianMaritimeDirectorateundertakescontrolofdelegated supervisory authority. This indirect/paramountcontrol aims atreassurancethat systemsand working forms employed function as designedandleadtotheintendedresults.Thisindirectcontrolconsistsmainlyofthreekindsofcontrols:– System audits.Auditscheckthattheclassifica
tion societies have a satisfactory system foraddressing the assignments agreed. In addition,spotchecksareperformedatheadofficesand field stations in order to check that theclassificationsocieties’representativesarefollowingthepreconditionsstatedinthedelegationagreement,intheinternationalregulatory
system, in the companies’ own rules andinstructionsandintheproceduresandinstruc
tionsissuedbytheNorwegianMaritimeDirectorate.
– Vertical audits. Here representatives of theNorwegianMaritimeDirectoratewillfollowaninspectionperformedbyaclassificationsoci
etyinconnectionwithcertificaterenewalsoastoreassurethemselvesthattheclassificationsociety has performed its duties as agreed.Representatives of the Norwegian MaritimeDirectorate can also let the class inspectorundertakehiscontrolfirstandmakehiscomments,andthenthemselvesinspectafterwardsandmaketheirowncomments,whichcanbecomparedwithwhattheclassificationsocietyhasfound.
– Surprise supervision.Inadditiontotheperiodicinspections,surpriseinspectionsonboardare
alsoundertakeninordertoconfirmthatthe vessel’s technical standard is in conformity with regulatory requirements. Here the Nor wegianMaritimeDirectorateinspectstheship without the classification society beingpresent.AftertheinspectionanexpertpanelintheDirectorateconsiderstheresultsandfindings of the control, and if necessary undertakesfollow-upoftheclassificationsociety.
3.5.3.5 Control of seafarers The Norwegian Maritime Directorate performscertificationofNorwegianmaritimepersonnelafterapriorcontrolofdocumentationinaccordance withtheSTCWConvention.
3.5.3.6 Control of the environment
Control that stipulated requirements for designand operation related to prevention of pollutionarebeingcompliedwithareapartoftheordinary vesselcontrol.
3.5.4 The classification societies’ own workoutside the public regulatory system
As mentioned above, the classification societiesbegan their work before the public sector. DetnorskeVeritaswasestablishedin1864,andothersocietieswereactiveevenbeforethattime.Atsea,therefore, the private sector was the first to dosafetywork.Thedrivingforcebehindthisdevelopmentwasthemarineinsurancebusiness.The
classificationsocietycaninprincipleperformitsservices on all ships irrespective of nationalityandwaters.Validclasscertificatesareaprecondi
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tionfortheshipbeingabletoobtaininteraliainsuranceandflag-stateregistration.
Theclassificationsocietiesbasetheirworkonself-developed rules for ship design and equipmentasregardsstrength,integrityandsafeoper
ations. The rules of the classification societiestake account, however, of the international con ventionsandtoalargeextentmakesupplementaryprovisionstothese.TheNorwegianregulatorysystemhasmadetheclassificationsocieties’regulatory system binding by means of referring tothelatterintheseareas.Thismeansfirstandforemostrulesfortheships’integrity,hull,enginesandothertechnicalinstallationsontheship.Theclassificationservicemeansthattheship’sdesignistobeapproved,thattheshipshallbeinspectedthroughouttheconstructionperiod,thatsubcon
tractors’deliveriesofequipment,asforexamplemainengines,boilers,electricalsystems,pumps,etc.aretobeapprovedbeforedeliverytotheship yard, and after delivery from the shipyard theship istobeinspectedviaperiodicandother inspections throughout her lifetime.On this basisthe class certificate is issued, to certify compliancewithregulatoryrequirements.
Inprinciple classification isvoluntary forthecompany and neither international nor nationalprovisionsmakedirectrequirementsforclassifi
cationofships. The “Bourbon Dolphin” was classed in DNVand had consequently tosatisfy theirregulatorysystem.
3.6 Brief summary of the Britishregulatory system for anchor-handling operations
3.6.1 Introduction
Theapplicableregulatorysystemisextensiveandconsists,besidesactsandregulations,ofseveralothersourcesoflawaswell.AsinNorway,thereisadivisionbetweenthemaritimelegislation,thepetroleum legislation and the shoreside legislation.Inbothcountriestheshoresideregulatorysystem has been givenapplication topetroleumactivity, and in addition a number of ruleshavebeenpromulgatedfortheoffshoreactivityinparticular.
Themethodologyof theregulatorysystemisinmanywayssimilartowhatwefindinthesafety
regulationofthepetroleumactivityinNorway,in whichactsandregulationsareformulatedasfunctionalrequirements(intheUKlabelleda“goalset
tingregime”).Thismeansthattherulespresentgoalsandprinciplesinwhichitisstatedwhattheauthoritieswishtoachievethroughtheregulatorysystem.Therulesaretherebytoalargeextent vaguelyformulated,whichcreatesdifficulties for
theworkoffindingoutwhatneedstobedonetomeettheregulatorysystem’srequirementsonthebasisofactsandregulationsalone.
Like the Norwegian regulatory system, theBritish regulatory system also makes requirements for health, environment and safety. Theregulatory methodology is broadly speaking amatterofissuinggeneral,formalrulesinwhichthe objective is formulated, whereas the playershavea certaindiscretionasregardshowtheob jectivesare tobeachieved.Forsomeregulatorysystems,a guidanceor approved code of practice
(ACOP)hasbeenprepared.Thesecodesarenotlegallybindinganditisuptotheplayerswhethertheywillmakeuseoftherecommendedsolutions,inthesensethattheymayselectothersolutionsaslongastheselectedsolutionsmeetformalrequirementsinactsorstatutoryregulation.Itisdifficult to determine whether a selected solution will meet the requirements of extremely vaguestandards,andthismustbedonethroughaconcrete assessment. As the last link in the chain, work standards or recommendations have been
prepared;thesemayberegardedasconstituting“relevant good practice”, and are usually moreconcretein theircontent. The standardsarenotbinding,butarerelevantaslongastheyprovidean indication of how the vaguely formulated requirementsofthebindingregulatorysystemcanbemet.Theymaybepreparedbytheauthoritiesorbyvariousprivateorganisations.
3.6.2 General requirements for safety andhealth
ThekeypieceoflegislationinBritishsafetyregulationistheHealthandSafetyatWorketc.Actof1974.ThiscorrespondsinmanywaystotheNor wegian Working Environment Act, and consequentlyshowsthesignsofhavingtogovernmanydifferentworksituations,fromrailwaytransporttomining.Thereexistsnoapproved code of practi
ceor guidancetotheAct,butanumberofstatutoryregulationshavebeenpromulgatedunderitsauthority.
StatutoryRegulationsconcerningthescopeof
theActhavebeenpromulgatedunderthetitleof“TheHealthandSafetyatWorketc.Act1974(Application outside Great Britain) Order 2001 No.
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2127”(abbreviatedasAOGBO),ofwhichSection4(1)statesthattheActappliesto“anyactivityinconnectionwithanoffshoreinstallation…”.Towingoperationshaveneverthelessbeenexemptedfrom the Act via regulations, but the operation
with which the “Bourbon Dolphin” was inprogresson12Aprilcannotberegardedasatowingoperation,sothattheexceptionisnotapplicable.Therig’sdrillingactivitywasapartofChevron’sexplorationoperationsandappraisalofapetroleumfield.Itisthereforemostnaturaltoviewtheoperationofmovingandmooringtherigasa wholeandthereforeaspart of thepetroleumactivity,ratherthanasamaritimeoperationinwhicheach individual vessel’s behaviour is consideredinisolationundermaritimerules.TheconclusionistherebythattheActisapplicabletotheopera
tioninquestion.Bywayofintroduction,theHealthandSafety
atWorketc.Act1974Part1indicatesanumberofgeneraldutiesincumbentontheemployerortheself-employedinrelationtothesafetyofemployeesandothers.
Section2dealswithanemployer’sgeneralduties in connection with his employees’ health,safetyandwelfare.Theemployerhasadutyundertheprovision,asfarasis“reasonablypracticable”,tosafeguardthehealth,safetyandwelfareof
hisemployeesinworkinghours.Anumberofaspectsarelistedthatthegeneralprovisionparticularlycovers,includinghavingsystems,premises,informationandtrainingandsoforthdesignedtosafeguardhealthandsafety.
Section3dealswiththeliabilityofemployersandtheself-employedvis-à-vispersonsotherthantheir own employees. Here it is a requirementthattheemployerandtheself-employedperformtheirtasksinsuchamannerthattheyensure,asfarasis“reasonablypracticable”,thatthirdparties are not exposed to any risk in relation tohealthandsafety.Theterm“reasonablypracticable”iscentraltointerpretingtherequirementforrespectivelysafeguardingtheemployees’health,safetyandwelfare(Section2)andnotlettingothersthanemployeesbeexposedtorisksinrelationtohealthandsafety(Section3).“Reasonablypracticable” is considered to bea narrower conceptthanwhatisactuallyphysicallypossible;thetermmeansthatonemustundertakeacalculationofthemagnitudeoftheriskontheonesideandtheeffortrequiredtopreventtherisk–whetherin
money,timeorotherinput–ontheother.Ifthereis a disproportion between these quantities, the
burdenofproofliesontheresponsiblepartytodemonstratethatitwasnot“reasonablypracticable”formeasurestobetaken.Ifanemployerdidnotknowabout,orhadnoreasontobeawareof,arisk,itmaybethatitwasnot“reasonablypractica
ble”totakemeasuresagainstit.Thelossofavesselisanaccidentofsuchdimensionsthatthereisnoroomforconsideringwhetheritis“reasonablypracticable”todowhateverisnecessarytoavoidtheloss.
Theconclusionis therefore thatanemployerhasawide-rangingresponsibilityalsoforothersthanhisownemployeesnotbeingexposedtoriskasregardstheirhealthandsafety.
That theoperationwasbeingperformedinalimited area, with a view to moving the rigthroughacoordinatedoperation,meansthatthe
assignment must be deemed to be performed within the principal’s area, both geographicallyandactually.
Thismeansthat theoperator, astheultimateprincipalandresponsibleforananchor-handlingoperation,hasaresponsibilityforthesafetyalsoof the crew on a hired anchor-handling vessel withwhichhedoesnothavea directcontractualrelationship.
The Management of Health and Safety at WorkRegulations1999,whichisalsoapplicableto
offshore installations and connected activities,containsprovisionsonriskassessmentsingeneral,conferSection3.An Approved Code of Practice
hasbeenissuedinrelationtotheRegulations. TheACOPdescribesriskintermsoftheprob
abilitythatapotentiallossorinjurywilloccur:thescopeoftheriskwilldependontheprobabilityforthelossorinjuryoccurring,thegravityofthelossorinjury(orthenegativehealtheffect)andthenumberofpeoplewhomaybeaffected.Theriskassessmentshallinteraliaidentifyhowtheriskmay arise and take effect, so that decisions onhowtohandletheriskmaybetakeninawell-informed, rational and structured manner and sothat the measures implemented are proportionate. The risk assessment shall cover everybody whomightbeaffected.
Therearenohard-and-fastrulesforhowariskassessment isto bedone,sincethiswilldependonthenatureoftheworkortheactivityandthetypeofdangerorrisk,butundertheACOPitisarequirement that whatever the risk assessmentuncoversshallbewrittendown.Whennecessary,
for example because it is found that the risk ischanging,theriskassessmentshallberevised.
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3.7 Guidelines for the safe managementof offshore supply and anchor-handling operations in the NWEA
3.7.1 General
The Guidelines for the safe management of offshore supply and anchor handling operationsNWEA(NorthWestEuropeanArea)dealwithanchor-handlingoperationsandapplytotheareain whichtherigmovetookplace.TheyenteredintoforceinFebruary2006andreplacedtheUKOOAintheBritishSector.
The guidelines are additional to national requirementsmadebytheShelfstate.NWEAdoesnot replace national requirements, but “adherence….willprovidestrongindicationtonational
administrationsthatthehealthandsafetylegislationisbeingmetandduediligencetaken”,conferNWEASection1.5.2.
Thescopeisnot restrictedto individualcountries’ continental shelves or ships, but includes“allthoseinvolvedininteractionbetweenoffshoreinstallations, bases and offshore service vesselsrelatedtooffshoreoperationsintheNWEA”,conferSection1.42.
Masters are “at all times responsible for thesafety of their crews, vessel and cargo…” and
“must stop operations that threaten the safety ofthevessel…”,conferSection2.2.1andSection6.1.5first paragraph. Both in this provision and else where in the guideline it is pointed out that themaster’sprofessionaljudgmentwithregardtothesafetyofthevesselandcrewmustnotbeaffected.
Foritspart,thecompanyisresponsibleforthe vesselbeing“correctlymannedandequippedforthe assignment”and that “an operationalplan isprepared for all anticipated onboard operationsandservicesprovidedbythevessel”.PursuanttoSection2.2.3.3thecompanyshall“prepareoperational conditions for the vessel” and “define requirementsforsafeoperationofthevesselunderallconditions,andanyvessellimitations”andensure that a copy of the guidelines are “kept onboard”andthat“theircrewarefamiliarwiththecontent”.
Section 6 contains specific rules for anchor-handling and towing. By way of introduction,there is a warning that anchor-handling operationsandtowingmaybedangerousandthattheinstallationpersonnelmustbeawareoftheves
sel’soperationallimitations,conferSection6.1.Section6.1.2makestheoperatorcompanyre
sponsibleforobtainingthenecessaryanchor-han
dlingvessels,deployingofequipmentandpersonnel,obtainingweatherandwavedata,organisingtherigmovemeetingandbriefingthemastersbefore the vessel leaves port. Under Section 6.1.3therigownerisresponsibleforpreparationofrig
moveprocedures,but thistaskmayalsobeperformedbytheoperator.Section6.5.3,Othernecessaryinformationfor
rig move procedures, includes provisions on weather criteria, weather window and time estimate.
Section9containsprovisionsontraining,qualificationsandmanning.
Sections9.2.4.2and3laydownthefollowing:
“Masters with no previous A/H experienceshouldperformatleastfiverigmovestogether
withanA/Hexperiencedmaster,orasuitablecombinationofrigmovesandsimulatortraining,beforetheymaycommandanA/Hassignment. Ship Owner shall document Master’scompliancewiththis.A/Hexperiencegainedinachiefofficerroleisacceptable.
…Officers require relevant expertise. They
shallbefamiliarwithoperationalguidelinesonsafety,andwithsafeuseofequipmentandlimitationsofequipment.”
3.7.2 Risk assessments
Chapters6and7oftheNWEAguidelinescontainprovisions that risk assessments shall be performedfortheoperation,andSection6.9givesareminderthathandlingofanchorsindeepwatercarries “significant additional hazards”. Section7.1maintainsthat“goodriskmanagementisakeycomponent to successful safety management”, whereas Section 7.2 states that the objective ofriskassessmentandsafejobanalysesistoeliminateorminimisetoacontrollablelevelhazardsandrisks.”Ifrisksorhazardscannotbecontrolled, the work should not be carried out, conferSection7.1.1.
Allpartiesinvolvedinanoperationareobligedtoensurethatriskassessmentsaredonecorrectlyandthatthepersonnelhasreceivedtrainingindoingso,conferSection7.2.3.
The players’ responsibility for preparation ofriskassessmentsisallocatedasfollows:– Theoperatorisresponsibleforadequateplan
ningandriskassessmentfortheentireanchor-
handlingoperation,conferSection6.1.2.2.– Therigownerisresponsiblefortherigmoveproceduresbeingreviewedwithparticipating
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vesselsandkeypersonnel, that this isunderstoodandtheriskassessmentisperformed,conferSection6.1.3.4.
– OilInstallationManagersareresponsibleforensuringthatriskassessmentsareperformed
foroperationsonboardtheirinstallationandliasingoverRAsinvolvingvessels,conferSection7.2.3.Intheeventofalterationofordeviationfromtherigmoveprocedure,theOIMisresponsible for performing new risk assessments.
– Mastersareresponsibleforriskassessmentsfor the operation being performed on boardtheirvesselandforliasingwiththeinstallationandthebases,conferSection7.2.3.
Riskassessmentsshallbepreparedbeforetheoperationcommences.Ifanoperationischangedin
relationtotheoriginalplanforwhichtheriskassessmentwasperformed,theparticipantsintheoperation must review the hazards and risks oftheamendedoperation.
3.8 Operational standards forperformance of marine operations
For performance of marine operations operatorcompaniesmustobserveindustrialguidelinesfor
among other things to identify probable forces. This section will illuminate operational limitations, requirements for weather windows (i.e. weather forecasts that mean that the operationcan be performed) and the significance of the weatherconditions for the vessels’ availablebollardpull.
Critical elements for offshore operations areuseoftimeandexpectedweather.Planningofmarineoperationsshouldbebasedonanoperation’sreferenceperioddefinedas:Operationreferenceperiod(TR)=Estimatedtimeofoperation+Estimatedunforeseentime.
Ifunforeseentimehasnotbeenidentified,theoperationreferenceperiodisnormallysetattwicetheestimatedoperationtime.Marineoperations withareferenceperiodlessthan72hourscanbedefinedasweather-limitedoperations.Theseoperationscanbeplannedindependentlyofstatisticaldataandbasedonlyonweatherforecasts.
Forweather-limitedoperations,criticalfactorssuchasforces,movementsandaccelerationshallbecalculatedinaratherworseweathercondition
(designcriterion)thantheweatherinwhichitisplannedtoperformtheoperation(operationalcriterion).Thisisduetotheunreliabilityofweather
forecasts, weather that suddenly blows up, andtheuncertaintiessurroundingtheassessmentoftheweathercondition.Thelongertheplannedoperationlasts,thegreaterthedifferencebetweentheoperationalcriterionandthedesigncriterion.
Therelationshipbetweentheoperationalcriterionandthedesigncriterionisdefinedastheáfactor,ref.Table3.1.Thevariationsinthealphafactoralsotakeaccountofthefactthatitishardertoestimate the wave height for small sea conditionsthanforlargerseaconditions.ValuesreferredtointheDNVRulesforMarineOperations,Part1,Chapter2,Planningofoperations,areshownin Table 3.1. As an example, operation planned totake20hourswithadesigncriterionofsignificant wave height (Hs) 2.5m will yield an operationalcriterion of 2.5 * 0.71 = 1.8m. Significant wave
heightisdefinedasthemeanofthe1/3highest waves.Themaximumwaveisabout1.86timesHs(dependingontheperiod).
Recognised industrial standards say that accountshallbetakenofthefactthatthevessel’scontinuousbollardpullwillbereducedbyweatherforcesduringtheoperation.
3.9 Requirements for the mooringsystem of the “Transocean Rather”
Thedrillingrig“TransoceanRather”isclassedinDNV.TherigdoesnothavethePOSMOORclassnotationfromDNV.ForthisreasonDNVdoesnothave responsibility for follow-up with respect tothe mooring system over and above its use foremergencymooring.
DNVisalsoengagedbyTransocean(UK)asanIndependentCompetentPerson(ICP)inconnection with statutory shelf-state verification(HSE).TransoceanRatherSafetyCase(no.1729,2004)wasacceptedbytheHSE.
Table 3.1 Significant wave height alpha values
Operational Designwaveheight(m)period(hours) 1 Hs 2 2<Hs4 Hs>4
TR<12 0.68 0.76 0.80 TR<24 0.63 0.71 0.75 TR<48 0.56 0.64 0.67 TR<72 0.51 0.59 0.63
Forsignificantwaves(Hs)thealphafactorsreferredtoinTable3.1shallbetakenintoaccount.Forwind(10min,mean),analphafactorof0.8shallbetakenintoaccount
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Asatechnicalreferencefor themooringsys- Inaddition,Clevrondemandedthat themoor-temDepartmentofEnergy4thEditionGuidance ing system satisfied the POSMOOR require-Notes32.2,MODUCodepart4.11.8andinternal ments. Transocean specifications was chosen by Transocean.
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Chapter 4The company
4.1 Organisation
Bourbon Offshore Norway AS is a Norwegiancompany with about 500 employees, of whommostworkonthecompany’svessels.ItisheadquarteredatFosnavåg,MøreogRomsdalCounty,
Norway. The company’s vessels are formallyownedbyBourbonShipsAS,butthiscompanyis wholly-ownedbyBourbonOffshore NorwayAS. Thecompanycurrentlyhas16vesselsinits fleet,of which five are anchor-handling vessels. Theother vessels of the company are supply ships(Platform Support Vessels,PSV) and MultiPurposeSupplyVessels(MPSV).Thecompanycur
rentlyhastenvesselsunderconstruction.In2006Bourbon Offshore Norway AS posted sales ofaboutNOK880million.Thecompanyisapartof,and is owned by, the multinational BourbonGroup,withabout4,200employeesand280vesselsinitsfleet,headquarteredinMarseilles.
BourbonOffshoreNorwayAS’organisational
structureisshowninFigure4.1.
4.2 Crews during the operation
The“BourbonDolphin”wassetupwithtwoshiftsthatwentfiveweeksonandfiveweeksoff.FrankReiersenwasmasterwhenthevesselwaschar-
Figure 4.1 Organisational chart for Bourbon Offshore Norway AS, April 2007
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teredandduringthefirstpartoftheoperation,seeSection8.3.Afterthecrewchange (seeSection8.2)on30March2007,thecrewcomprisedthefollowing14persons:
Watch1OddneRemøy(Master)KjetilRuneVåge(FirstOfficer)FrankNygård(ChiefEngineer)PerJanVike(AbleSeaman) TorKarlSandø(AbleSeaman)
Watch2BjarteGrimstad(ChiefOfficer)GeirToreSyversen(FirstOfficer)RonnyEmblem(FirstEngineeringOfficer)ØysteinSjursen(OrdinarySeaman)
EgilAtleHafsås(AbleSeaman)
Daycrew ÅnjeNilsen(cook)SørenKroer(electrician) ThomasArnesen(engine-roomtrainee)KimHenrikBrandal(engine-roomtrainee)
The first watch worked from 06:00 to 12:00 andthereafterfrom18:00to24:00.Nilsen,Kroer,ArnesenandBrandalstoodregular10-hourwatches
from08:00to18:00.OddneRemøywastheregularmasteronthe“BourbonBorgstein”,butathisownrequestandbyagreementwiththecompanyhadexchanged watches with the other regular master on the“BourbonDolphin”,HugoHansen.Thecompanyconsidered the “Bourbon Borgstein” an equivalentshipandtheexchangeofcaptaincieswasregarded as not being any kind of problem. This wasRemøy’s firstvoyagewiththe“BourbonDolphin”. His fourteen-year-old son, David Remøy, wasalongasapassengerandasworkexperiencefromlowersecondaryschool.
First Officer Geir Tore Syversen, who hadbeenabridgetraineeonthe“BourbonOrca”,wasalso on his first voyage with the “Bourbon Dolphin”, whereas Chief Officer Bjarte Grimstad, who stood watches together with Syversen, hadbeensailingwiththe“BourbonDolphin”from14October 2006. The “Bourbon Dolphin” was thefirst anchor-handling vessel on which he hadserved. The rest were the usual crew of the“BourbonDolphin”.AbleSeamanØysteinSjursen
hadcomeonboardwithCaptainFrankReiersen’s watch,butstayedonbecausethemusteringcrew wereonemanshort.
OnthebasisofinformationfromthecompanytheCommissionfindsthatthedeckofficers’experienceofanchor-handlingwasasfollows:Remøy16months,Grimstadsixmonths,Våge15monthsandSyversensixweeks.RemøyandVågehadpar
ticipated in a number of rig moves previously, whereasGrimstadhadbeenonnineassignments,ofwhichfourwereregularrigmoves.Remøyand Vågehadexperiencefromdeep-wateroperations, whereas Syversen and Grimstad had no correspondingexperience.
WhenOddneRemøytookupthepostofChiefOfficeronthe“BourbonBorgstein”,hehadnotparticipatedinfiverigmoves.Amonthlaterhe waspromotedtomasterwithouthavingparticipatedinfiverigmovesasChiefOfficer.Atthetimeoftheaccidenthesatisfiedtherequirement.Bjarte
Grimstad,who joined the “BourbonDolphin”asChiefOfficerinOctober2006,hadabackgroundfromsupplyshipsand–sotheCommissionhasbeentold–hadnoexperienceofrigmoves.Whentheaccidentoccurred,Grimstadhadparticipatedinfourregularrigmovesandtakenpartinanassignmenttoresetananchor.
ChiefEngineerNygårdhadnineyearsservice, whereas First Engineering Officer Emblemhadfouryearsservice.Thedeckcrew’sexperience of anchor-handling was: Sandø six years,
Vikeninemonths,HafsåsfivemonthsandSjursenfivemonths. TheCommissionwouldparticularly notethat
noinformationhasbeenreceivedthatwouldsuggestthatthecrewmemberswerenotphysicallyandmentallyfittostandwatchonthedayoftheaccident. The Commission finds that the provisions on working and rest time had been observed.Thisappliedtobothwatches.
4.3 The company’s safety management
system
BourbonOffshoreNorwayAShasasafetymanagementsystemthatbyandlargeisthesameforthe entire fleet, but with certain adaptations foranchor-handling vessels. The system was establishedin2003andhasbeensubjecttocontinuousamendmentsince.Thesystem,whichisinEnglish,isdividedintotwelvesections.Thefirstsectionsdealwiththecompany’ssafetypolicies,division of responsibility and authority. Thereafter
comesadescriptionofthemaster’sresponsibility,resources and personnel, and ship’s operationsandpreparedness.Thelastsectionsofthesystem
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concern reporting, maintenance, documentationandthecompany’sownreviewandevaluationofthesafetymanagementsystem.
Bywayofintroduction,thesystemprescribesthatitshallconformtotheISMCode,ISO9001
and ISO14001.Amongthe company’sobjectivesare the satisfaction of the obligatory regulatorysystem, and to “address applicable codes, guidelines…”.Thecompanyalsohasitasanobjectivetocreate adequate safety barriersagainst all identified risks in the activity. The company shall alsocontinuouslyimprovesailingandshore-basedpersonnel’sknowledgeofboththecompanyandthe vesselasregardstheuseofthesafetymanagementsystem.Thisappliestopreparationsforhandlingemergenciesthatarebothsafetyandenvironment-related,plussafehandlingofvesselandworking
environment.Inordertohandlethis,thecompany’sintentionistoestablish“functionalelements”in its safety management system: among otherthings procedures for identifying, evaluating andreducingriskthatcanleadtohazardoussituations,errors and undesirable incidents, confer Section1.2ofthesafetymanagementsystem.
The company is organised with a ManagingDirector (Trond Myklebust) leading the company. Underhim is the Operation Director (BjørnIdarRemøy)towhomthemastersofthevessels
report. Technical Manager Bjørn Bergsnes was appointedtoBourbonOffshoreon1April2005.Between2001and2002hehadbeenemployedinthedesigndepartmentoftheUlsteinVerft.In2002hebecamedesignmanager.
The Designated Person Ashore, confer ISMCodeRule4,isEliOksavik,withwhomthesailingpersonnel can take direct contact. Oksavik reportsdirecttotheManagingDirector.TheDesignated Person Ashore’s responsibility includesmonitoring of safetyand prevention of pollutionduringtheoperationofthevessel,andensuringthat shore-based support is available when required.UnderthesafetymanagementsystemtheDesignated Person Ashore is also assigned responsibility for performing internal audits. TheDesignatedPersonAshorealsohasindependenceandauthoritytoreportnon-conformancestocompany management and take remedial measuresforsuchnon-conformances.
Section5.1.providesajobdescriptionforthemaster.Amongotherthingshehastheresponsi
bility for implementing the safety managementsystemonboardandformotivatingthecrewtocomplywiththecompany’ssafetypolicybydis
playing expertise and a positive attitude to thesafety managementsystem. Itis alsostated thatthemasterhas“overridingauthority”toaddresssafetyandtheenvironmentandtheefficientoperationofthevessel.Italsofollowsfrom5.1.1that
themasterrepresentsBourbonOffshoreNorwayandhastheresponsibilityforprotectingtheinterestsofthecompany.Themastershallalsocreategoodrelationswiththecharterer’spersonneland“strictlyfollowallordersgivenoftheCharterer”,providedthattheseareinconformitywiththeflagstate’srulesanddecisionsofpublicauthorities.
ItfollowsfromSections6.2and6.3thatpersonnelonboardshallsatisfytheSTCWConvention.Thereare,however,nowrittenqualificationrequirements for bridge personnel over andabovetherequirementsoftheSTCWConvention.
Itisstatedthatnewpersonnelshallbefamiliarised with the vessel’s safety system and job descriptions,andthatitisthemaster’sresponsibilitytoensurethatthisisdonebeforethevesselleavesport.Thesafetymanagementsystemdoesnotaffectoverlapfornewpersonnel,norarethereexpressrequirementsforthisintheSMCode.Thecompanyhaspreparedchecklistsforfamiliarisation (Safety Induction Checklist). See Annex 1Section2.4.
ItisalsostatedinSection6.5thatthecompany
shall continuously identifynecessary training ofcrew and company personnel in support of thesafetymanagementsystem.
Section7.5makesrequirementsthatworkassignmentsthatarenotcoveredbytheship’sregular procedures, and where there is a potentialrisk,beanalysed inorder todetermine whethertheriskcanbereducedorremovedbychangingtheworkmethod.
Under the system the risk analysis shall beperformedinthefollowingmanner:
Assesstherisk:• Whatcangowrong?• What are the consequences if something
shouldgowrong?
Analysehowtheriskcanbereduced:• Doesthepersonnelhavethenecessaryskills
toperformthejobsafely?• Isthereaneedforfurthertraining?• Isthecorrectpersonalsafetygearbeingused?• Isthecorrectequipmentavailable?
Thecompanyhas anelectronicsystem(Premaster)tosupporttheperformanceofriskanalyses.
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Section8dealswithcontingencyproceduresanddrillsandamongotherthingsdemandthatafire and evacuation drill be held once a month, whereas drills simulating damage to the hull,grounding or collision hazard shall be done at
leastonceayear.Reporting, investigation and closing of non-conformances are described in Section 9. Accidentsandnon-conformancesthataffectthevessel’soperationalabilitiesorsafetyshallbereported,investigatedandclosedbythemasterafterthecorrectivemeasureshavebeentaken,withaviewto the incident not repeating itself.For itspart,thecompanyshallmonitornon-conformancesandfollowupthecorrectivemeasures.
Section10listsdetailedroutinesforthemaintenance of the vessel and equipment, with a
numberofappurtenantprocedures,whereasSection11dealswithdocument-handling.
Section12.1prescribesthatannualinternalauditsshallbeperformedbythecompanyinordertoverifythatthesystemhasbeenimplementedcorrectly.Inthecourseofafive-yearperiod,theentiresystemmusthavebeenrevised.TheMaster’sReview,whichisacontinuousprocess,shallgivecompanymanagementsufficientinformationabouthowthesystemisimplementedonboard,conferSection12.2.Atleastonceayear,company
managementshallgothroughthesystem(Management Review) and consider how it is implemented,conferSection12.3.
Thecompanyalsohas anAnchorHandling& Towing Manual, see Annex 1, Section 2.2. Themanualisgeneralandaffectsonlysomeofthefundamentalprinciplesofanchor-handlingonaparamountlevel.Themanualisnotvessel-specificandlacksadescriptionofoperationsindeepwater.
ItisnotapparentfromthesafetymanagementsystemthattheNWEAguidelinesforanchor-handlingaretobefollowed,butthecompanyhasstatedthatintheautumnof2006theysenttheguidelinestoallitsvessels.
The foregoing description of the safety managementsystemisbasedonhowitappearedatthetimeoftheaccident.ExtractsfromthesystemhavebeenincorporatedintoAnnex1Section2.1.
4.4 Provisional certificationof 3 October 2006
Provisionalcertificationofthe“BourbonDolphin” wasmadeon3October2006byDNV,whenthe vesselwastakenoverbytheowner.Asmentioned
above,thecompany’ssafetymanagementsystemisroughlyspeakingthesameforallthevesselsinthecompany,andacorrespondingsystemwasestablishedonthe“BourbonDolphin”.Noauditofthesystem was undertakenondelivery,andthe
vessel received provisional certificates with sixmonths’validityinconformitywiththeISMCode.
4.5 Internal audit of 9 March 2007
SafetyOfficerStevenRooneyfromthecompanyofficeperformedaninternalauditonthevesselon9March2007andpreparedareportdated15March, see Annex 1 Section 2.5. In the audit,Rooney reported three non-conformances andfive observations. Two non-conformances con
cerned“security”,confertheISPSCode,whereasthe third non-conformance concerned defectivesignatureofthehandoverform.RooneytestifiedbeforetheCommissionthathandoverwasalwaysperformed, and that itwas thus only the actualsignaturethatwasmissing.Twooftheobservations concernedrisk assessmentsand reportingroutines.Regardingriskassessmentsitwasstated:
“Theriskassessmentsystemcouldbebetterused.Ithasmostlybeenusedbeforestart-upof
anchorhandlingwork”(original in English)
TheobservationrelatedtoreportingroutinesconcernedtheuseofthesystemPremasterinnonconformancereporting.Theinternalauditreportpointedoutthattherewaslittlereportingthroughthe system, particular as regards improvementproposalsandundesirableincidents,andthatthiscouldbeimprovedbyalldepartmentsonboard.
4.6 DNV’s audit of 17 March 2007
Certificationofthecompany’ssafetymanagementsystemisaflag-stateresponsibilitythattheclassification societies discharge onbehalf of Norwegian authorities for cargo ships registered inNOR. With its delegated authority, DNV performedthecertificationofthesafetymanagementsystemofthe“BourbonDolphin”.Theinitialaudit was done by Chief Auditor Richard Taylor atDNV’slocalofficeinAberdeenon17March2007,see Annex 1 Section 2.6. He stated before the
Commissionthathehadonlyoncebeforeauditedthesafetymanagementsystemofananchor-handlingvessel.
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In his witness testimony to the Commission(conferAnnex2Part5),Taylorstatedthathehadspokenwithseveraloftheofficers,amongothersCaptain Reiersen, and some of the deck crew.Duringtheaudithewasshowntheinternalaudit
dated9March.InhistestimonyTaylormentionedthattheauditmethodologywastodospotchecksonvariouscomponentsofthesysteminordertoensure that it was functioning in a satisfactorymannerasawhole.
The audit uncovered four non-conformancesin the system. The first non-conformance concerneddefectivecompliancewithroutinesrelatedtothefamiliarisation(induction)ofnewcrew,confertheISMCode’sRule6Section3.Thesafety management system’s Section 7.2 demandsthatnewpersonnelshouldimmediatelyfamiliar
isethemselveswiththe“VesselInductionBooklet”andbegivenanintroductionbythevessel’sSafety Officer. The non-conformance in the reportwasrelatedtothefactthatthecompanyhadpreparedspecificchecklistsfordeckandengine-room that were not being used. The companyhas stated that the specific checklists, which were an improvement measure for familiarisation,wereintroducedinJanuary2007.Thecompanyhas,however,ageneralchecklistforfamiliarisationthatisalwaysgonethrough.Inhistes
timonyTaylordefined“newpersonnel”ascrew whohadnever worked on thevessel previouslyorwhohadnotbeenonboardforawhile.IntheintroductorypartoftheSafetyInductionChecklist, new personnel are defined as those whohave never been on the vessel before, or whohavenotbeenonboardfortwelvemonths.TheQualification Requirements Section 1-3 secondparagraph d)demand that new personnel shallbe familiarised with the vessel, equipment andtheirduties.
The other non-conformances concerned defectivedefinitionoftraininglevelforcertainpositions,interaliathewinchoperatorandpersonnel whoworkedondeck.TheSTCWConventionandtheQualificationRequirementsdonotmakespecial requirements for personnel on anchor-handlingvessels,buttheISMCode’sRule6Section5demands that the company identify the trainingnecessaryassupportforthesafetymanagementsystem. This means that the company must undertake an independent assessment of whethertheirpersonnelpossessthequalificationsneces
sary for the operations and duties to be performed.
During the hearing in Ålesund Bjørn IdarRemøy stated that the company demanded thatboththemasterandthechiefofficerhaveparticipatedinfiverigmovesbeforetheycanobtainpromotiontotheseposts.Sucharequirementisnot,
however, enshrined in the safety managementsystem. The NWEA guidelines recommend thatthemastershouldhavecompletedatleastfiverigmoves.ThisissueisdescribedingreaterdetailinSection3.7.
The third non-conformance concerned a defective procedure for anchor-handling. As mentioned above, the company has anAnchor Handling&TowingManualforanchor-handlingoperations,butTaylortestifiedbeforetheCommissionthatthiswasverygeneral.TheISMCode’sRule7.0demandsthattherebeaprocedureforall“key
operations”. Anchor-handling was the main purposeofthevessel.Taylorhadthereforeexpectedthatadetailedprocedureforanchor-handlingspecific to this vessel would be established in thesafety management system. Taylor also testifiedthatthedifferencebetweenamanualandaprocedurewasthat,whereasamanualisusuallygeneral,forexampledevelopedbyamanufacturerfortheirequipment,proceduresdescribevessel-specific processes. For its part, at the hearing in Ålesund the companydisputed the basis for the
non-conformances,andconsideredthatthemanualhadtoberegardedasbeingaprocedure.Bourbon Offshore later argued that anchor-handlingprocedures wereusually preparedbythe operator,andthatthecompany’sownanchor-handlingproceduresandmanualscouldthereforebegeneral.The companypointedout further that theyhadbeenauditedanumberoftimespreviouslybyDNV without this being classified as a non-conformance.
The last non-conformances concerned theanalysis of the company’s corrective measures. Taylor had uncovered through the audit thatthere existed recommendations from both theMaster’s Review and the Safety Committee regardingtheneedforcrewtraining.Thecompany,however,closed theserecommendationswithoutundertakinganyfurtheranalysisofthereasonfortheobservation,andreferredtotheplannedsimulator training, which for its part had been delayedduetodelaysinthedeliveryofthesimulator.
The short-term certificates were issued with
validityto16August2007.They arenormallyreplaced bya full-timecertificate withavalidityoffiveyears,issuedbyDNV’sheadoffice.
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4.7 Evaluation
4.7.1 Familiarisation/overlap
The ISM Code’s requirements for familiarisation
(induction)ofthecrewwereaddressedbytheuseof checklists that were controlled by the master. Thecompanyalsohasformsforhandoveratcrewchange. The systemhas, however, defective routinesforfamiliarisationofthemaster,andnotleastforwhohastheresponsibilityfortheimplementationofthis.Inpracticethemastermustgooverlapin order to verify familiarisation. By overlap ismeantthatthepersonabouttoservesailsforaperiodtogetherwiththecrewmembersheistorelieve,soastoacquirebetterknowledgeofthevessel’scharacteristics,herequipmentandcrew.Itis
also unsatisfactory that the system does not demandoverlapwhennewofficerscomeonboard.
The company defines in its forms “new personnel”asthosewhohaveneverworkedonthe vesselorwhohavenotbeenonboardforthelasttwelvemonths.Intheassignmentinquestiontwooftheofficers,CaptainOddneRemøyandFirstOfficer Geir Tore Syversen, were on their firsttourofdutyonboardandwerethusnewpersonnel. Through testimony from Captain ReiersenandSyversenitisclearthatacertainformforfa
miliarisationwasgiventothetwonewpeople.ForCaptainRemøy,thiswasonthehandoveron29March, a briefing that lasted about 1 ½ hours.HugoHansentestifiedinresponsetoquestioningfrom the Commission that he had held a telephone conversation with Oddne Remøy in ad vance.They alsoheldconversationsafter theoperationwasunderway.
The Qualification Requirements demand thatnewpersonnelbefamiliarisedwiththevesselandtheirdutiesonboard,conferSection3.4.Thevessel’s operational characteristics, including manoeuvringandstabilitycharacteristics,arekeyelementsofsuchafamiliarisation.
IntheCommission’sopinion,itisnecessarythatatleastpersonnelinseniorpostsgooverlapforacertainperiod.Itis,moreover,commonpracticein the industry thatof ficersgooverlap,anythingfromafewdaystoacoupleofweeks.TheCommissionwouldalsoemphasisethattheywerefacingademandingoperationindeepwater.Thetimeused was clearlyan insufficient familiarisationbasiswithinthemeaningoftheQualification
Requirements.Forsubordinatecrewsuchatime-frame may be sufficient, but particularly for amaster,withparamountresponsibilityforthesafe
tyofthecrewandvessels,overlapofacertainperiodwillbenecessary.AlsoforFirstOfficerSy versen,theCommissionconsiders thatthefamiliarisationgivenwasinsufficient.InitstestimonythecompanyhasnotedthatRemøyandSyversen
had worked on similar vessels (the “BourbonBorgstein”andthe“BourbonOrca”)andwerefamiliarwiththecompany’ssafetymanagementsystem.HeretheCommissionwouldpointoutthattherearematerialdifferencesbetweenthe“Bourbon Borgstein”, the “Bourbon Orca” and the“Bourbon Dolphin”, for example with regard toequipmentandvesselcharacteristics.Butevenifthevesselshadhadthesamedesign,itwouldnothavebeenproperforthemasternottogetfamiliarisationintheformofoverlap.
Itwasfirstandforemostthecompany’sdefec
tiveroutinesthatmeantthatRemøyandSyversendidnotreceivethenecessaryfamiliarisation,andparticularly in the case of Captain Remøy, theCommissionconsidersthatthisfailureledtohisnothavingsufficientknowledgeofthevessel.
4.7.2 Identification of training needs
Thecompany’ssafetymanagementsystemhastoasmallextent identified what levelof trainingisnecessary in order to perform anchor-handling
overandabovetheminimumrequirementsoftheSTCW Convention. DNV’s non-conformancesconcerned defective definition of the trainingneedsofwinchanddeckpersonnel.AsregardsSyversen,whowaswinchoperator,hehadundergone a six-week bridge trainee period on the“Bourbon Orca”. The Commission would alsopointoutthattrainingneedshadnottoanygreatdegreebeenidentifiedfordeckofficerseither,relatedtothedutiesthepersonnelaretoperform.
The guidelines for anchor-handling for theNorthWestEuropeanArea(NWEA),recommendthat,inordertofunctionasmasterofananchor-handlingvessel,apersonshallhaveparticipatedin at least five rig moves. As mentioned above,BjørnIdarRemøytoldthehearinginÅlesundthatthe companydemands thatboth the master andthechiefofficermusthaveparticipatedinfiverigmoves before they can gain promotion to theseposts, but no such requirement is enshrined inthesafetymanagementsystem.
WhenOddneRemøytookthepostofChiefOfficeronthe“BourbonBorgstein”hehadnotpar
ticipatedinfiverigmoves.Amonthlaterhewaspromoted master without having participated infiverigmovesasChiefOfficer.BjarteGrimstad,
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whojoinedthe“BourbonDolphin”asChiefOfficer in October 2006, had no experience of rigmoves.Thisshowsthatthecompany,inpromotingpeopletoleadingdeckofficerposts,didnotfollowitsinternalrequirementsasstatedtothe
Commission.Inthesecasethelackofidentification of training levels in the company’s systemmeantthatpostssuchasmasterandchiefofficer werebeing filled bypersonnelwithoutsufficientexperiencefromrigmoves.
IntheCommission’sopinion,itiscrucialthatcompaniesarefullyawarethatanchor-handlingisa risky, complex and demanding operation andthatforbothdeckofficersanddeckcrewitisnotsufficient to satisfy the STCW Convention. Thenecessityofidentifyingdifferentlevelsoftrainingandmanninginconformitywiththese,isthere
foreagreatone. The Commission would also emphasise the
importanceoftheauthoritieshavingaconsciousrelationshiptoqualificationlevels(confertheISMCode)incompaniesengagedinanchor-handlingandfollowingthisupthroughaudits.
TheCommissionhasalsonotedthattheBourbonGrouphaspart-financedasimulator inNor wayandhas its ownsimulators inMarseilleandSingapore.Theseareusedfortrainingofthecompany’spersonnel,whichisregardedasahighly
positivemeasureforthefuture.
4.7.3 Anchor-handling procedure
Ananchor-handlingprocedurecandescribewhatistobedone,inwhatwaytheoperationistobedone,whatforcesthevesselcanhandleandhowthey are to be handled, operational limitations, who is to do what, when the various operationsaretotakeplaceandsoon.Theprocedure,whichisanecessaryaidtoidentificationandhandlingoftherisks,shouldbevessel-specific.
In the Commission’s opinion the company’sgeneral manual cannot replace an anchor-handlingprocedure,notevenwhensupplementedbyanRMP.
IntheCommission’sopiniontheabsenceofananchor-handling procedure is a system failurethatcreateduncertaintyonboard.Notleast,thedeploymentofanchorno.2showsthatthecrewlacked operational instructions for correctivemeasures against uncontrolleddrifting and handlingofbigexternalforces.
As mentionedabove,BourbonOffshore Nor way has a safety managementsystem that in itsgeneral lines is identical for all the anchor-han
dlingvesselsofthecompany.Thesystemwasestablished in 2003 and ten or more audits musthavebeenheldofthecompany’svesselsandthecompanyofficesincethen.Itisthereforedifficulttounderstandwhythelackofananchor-handling
procedurewasnotpointedoutinpreviousauditsby DNV. This also indicates a weakness in theNorwegianMaritimeDirectorate’sauditsofDNV.
4.7.4 Other aspects of the safetymanagement system
In addition to the non-conformances uncoveredbyDNV’saudit,therearetwoaspectsofthecompany’ssafetymanagementsystemthatshouldbeemphasised.
Thefirstconcerns routinesforpreparationof
riskassessments.Asmentionedabove,thecompanyitselfhasstatedthatoneoftheobjectivesofthesafetymanagementsystemistoestablishsafetybarriersagainstallidentifiedrisks.Thesystemalsodescribeshowallrisksaretobeassessedandanalysedinsuchawaythattheserisksareasfaras possible reduced. This is in line with the requirementintheISMCode’sRule1Section2.2.2on introducing protection against all identifiedrisks affecting personnel, vessels and environmentalike.
The risk assessments prepared on the backgroundofstandardisedformswereinrealitysafe jobanalysesrelatedtothedangersofworkingondeckandotherhazardsthatcouldcauseinjurytothepersonnelonboard.Traininginthepreparation of risk assessments, as prescribed by theguidelinesforanchor-handlingoperationsNWEASection7.2.3,wasnotgiven
IntheCommission’sopinion,theimplementationofthecompany’ssafetymanagementsystemonboardsufferedfailure.Theyapparentlyhadasystemthatwastoidentifyeveryrisk,butknowledgeandunderstandingofriskstowhichthevesselassuchmightbeexposed,seemedtobelacking.Heretheconsequencesforthevesselofdrifting away from mooring lines could have beensubjectedtoariskassessment.
Intheinternalauditof9March2007itwasobserved that the preparation of risk assessments was defective, but this audit did not reveal thatriskstowhichthevesselwasexposedwerenotbeinghandled,Annex1,Section2.7.Thecompanywassupposedtohaveacontinuousfollow-upof
itsvessels,andthelackofimplementationofriskassessmentsoughttohavebeenuncoveredatafarearlierdate.
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In meeting with the Commission on10September2007theNorwegianMaritimeDirectoratestatedthattheyregardeditasunusualtoperformriskassessmentsforthevesselassuchduringanchor-handlingoperations,evenifthis,intheDi
rectorate’s opinion, follows from the ISM Code. Thisimpressionhasbeenconfirmedbyquestioningofwitnessesonothervesselsparticipatinginthe operation. The scopeand quality of risk assessments for anchor-handling operations haveapparentlybeendefectiveintheindustry.
Theotherweaknessconcerneddefectivenonconformancereporting.This,too,wasanaspecttouchedonintheinternalaudit.TheCommissionhasnoreasontoassertthattherehasbeenasystematicfailureofthenon-conformancereporting,butwillconcentrateontheheelingoffMongstad
inDecember2006,whichwasnotreported.The vessel sustained a list or roll of 5-7º when a 18tonneStevprisanchorslidacrossthedeck,anincident that ought to have been reported to thecompany,asdemandedinSection9ofthesafetymanagementsystem.Thiscouldhavebeenanoccasion for investigationswithinthe company regardingthevessel’sstabilitycharacteristics.
InconclusiontheCommissionwillmakesomeobservations on the non-conformance action inthecompany.Theshipyardpreparedloadcondi
tions among other things for anchor-handling, which following the heel test were sent to thecompany for comments. These comments werepreparedbyCaptainReiersen.Hemadespecificfeedbackonchanges,sothattheytoagreaterdegreedescribedrelevantoperations,andadesirefor supplementary conditions. The Commissionnotesthatthisdidnotelicitfurtherinformationfromtheshipyard,norwasanyrequestedbythecompany.NordidCaptainReiersen,asfarastheCommissionisaware,receiveanyfeedbackonhisenquiry.
4.7.5 The crew
Seeninrelationtothedemandingdeep-waterassignmentthevesselwasfacingontheRosebankfield,theexpertiseofthedeckcrewasawholeappearsinsufficient.Otherplayersintheoperationalsoobservedinexperienceonthepartoftheof
ficersonthebridge,amongotherthingstowmaster Ross Watson pointed to lack of experience with the use of anchor-handling equipment indeepwater.
InFebruary2007thecrewaskedforexpertise
enhancement ina simulator course, without thecompanyhavinggrantedtheirrequestpriortotheaccident.
Asmentionedabove,onereasonwhy thevesselhadabridgemanningthatwasrelativelyinexperiencedwiththiskindofoperation,isthatSection4.7.2ofthesafetymanagementsystemtoasmallextentidentifiedwhatqualificationrequirementsthecompanyoughttoimposeonofficersover and above the STCW Convention. It maythusbesaidthatdefectsinthecompany’ssystempermitted a composition of officers without the
necessaryanchor-handlingcompetence. Thecrew’s limitedexperienceof anchor-han
dlingingeneral,andofdeep-wateroperationsinparticular,mustalsobeseeninthecontextofinsufficientfamiliarisation.AspointedoutinSection4.7.1,thefamiliarisationofCaptainOddneRemøy wasinsufficient.Hewas therebygivencommandoveravesselhedidnotknowandacrewhehadnotworkedwith.Thetimeavailableforhandover wasmoreoverinsufficient inrelationtothecomplexityoftheoperationwhichtheyweretocom
mence,seeSection8.2.More experience among the officers on thebridgemighthavehelpedtopreventtheescalationofthecourseofeventsorcausedotherchoicestohavebeenmadeduringtheoperationthat wouldhavereducedthechancesofthecapsizing.HeretheCommissionisthinkingofthefactthattheoperationtodeployanchorno.2,followingtheproblemsencounteredbythe“OlympicHercules”undertheprevailingwave,windandcurrentconditions,wasstartedatall.Itisalsothinkingofthefactthatthebridgepersonnelpermittedthevesseltodevelopsuchaconsiderabledrift,andthattheoperationwasnotsuspendedwhentheybecameawarethatthevesselwasnotmanagingtoholdherposition,alsothe fact that the requestsfrom the engine-room to reduce thruster use were not granted. This is described further inChapter9.
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Chapter 5The “Bourbon Dolphin”
5.1 Introduction
ThevesselwasanewshiptypedesignatedA102(see Figure 5.1), developed by Ulstein Design, which is apart of theUlsteinGroup.Thevessel was built by Ulstein Verft with building number
274andwasoftheAHTStype(AnchorHandling TugSupply).
Construction of vessels must satisfy requirementsmadebytheflagstate,Norway,andtheclassificationsociety.Inadditioncomeotherspecifica
tionsthatthecompanyfindsitnecessarytoincorporateinrelationtothevessel’sareaofoperationaspartoftheconstructioncontract.Inthiscase,compliancewithIMOResolutionA.469(XII)andIMOResolutionA.534(13)wasapartofthecontract. Thevesselwas tobebuiltinconformitywiththefollowingrules:
• TheBuildingRegulations,conferSection3.2.• DNVRulesforClassificationofShips(issued
inJuly2004),withfollowingclassnotation: X1A1with thefollowingsupplementarynotations:
Figure 5.1 Ulstein’s presentation of the A102 design
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The heel test was performed on 20 August2006 and approved by the Norwegian MaritimeDirectorateon23August2006,seeAnnex1,Section1.2.
Thevessel’s lightshipweightwashigherthan
initially calculated. The original estimate was2,810tonnes(conferUlstein’sweightreports).Intheheeltesttheweightwasdeterminedas3,202tonnes.Themainreasonwhythevesselbecameheavierwasthat,accordingtoMøller’stestimony,there was inadequate control of the equipment weights.
Thevessel’svertical centreofgravitywas initially calculated at 7.17 m over baseline. In theheeltestthecentreofgravitywascalculatedat7.43 m. The vessel’s GM in lightship condition was0.29m.
Aswingtestaspart of theseatrialswasperformedinSeptember2006.Duringthistestarollangleofabout17°wasregistered.Thevesselwasthen, according to Per Gullik Strand of Ulstein,loaded in such a way that, with the prescribeddraughtoffivemetres,sheshouldhavetheoptimum (GM = 0.98 metres). In a new swing test with lower speed and less rudder, a smaller rollangle was registered. The Norwegian MaritimeDirectoratewasnotpresentduringthesetests.
On2October2006theNorwegianMaritime
Directorateapprovedthe vessel’sstabilityasregards limit curves, damaged stability, lightshipdataandruleconditions,andthevesselwasimmediately commissioned. She then had all thenecessarycertificates,seeAnnex1Section1.4.
5.3 The vessel’s arrangement
The vessel had a traditional arrangement for AHTSvessels–asuperstructurewithbridgeand various crew room forward, and an open deck
Table 5.1 Tank capacities
Type Capacity(m3 )
FuelOil 1205FreshWater 433 WaterBallast 1765Brine 583LiquidMud 627Slop 306BaseOil 173DryBulk 162RigChainLockers 522
areaaft,endinginanopensternwithabipartitestern roller. Over and above the superstructureforward, the vessel did not have buoyancy volumesabovethemaindeck.Thedeckhadanareaof485m2.
Thecompletedvesselhadadeadweightcapacityof2,130tonnesandthemaximumdeckcargo withacentreofgravity1moverthedeckcouldbe 740 tonnes. This deviated from the buildingspecifications,whichoperatedwithadeadweightcapacityof2,500tonnesandmaximumdeckcargoof800tonnes.Theoutlinespecificationsgivethemaximumdeckcargoat1,000tonnes.
Winches were placed aft of the superstructure,overthreedecks.ThewinchpackageisdescribedinmoredetailinSection5.6.
The vessel’s engines consisted of four main
engines(eachof3,000kW)placedtwobytwooneach side, linked to their own nozzle propeller. Thevesselhad three fixed tunnel thrusters, twoaftandoneforward,plusasubmersibleazimuthalthrusterforward.SeeSection5.5foramoredetaileddescription.
Thegeneralarrangement is shown inFigure5.2.
Anumberof tankscouldbeused forvariouskindsofliquid:• 4tankscouldbeusedforWaterBallast,Brine
orLiquidMud• 2tankscouldbeusedforWaterBallastandRigChainLockers
• 2tankscouldbeusedforWaterBallast,RigChainLockersandBrine
• 2tankscouldbeusedforLiquidMudandSlop• 1 tank could be used for Fresh Water and
WaterBallast• 2tankscouldbeusedforFuelOilandBaseOil
ThetankplanmaybeseeninFigure5.3.Ballast tanks were arranged with a view to
compensation for roll angle and trim, which isgenerallynecessaryinanchor-handling.
Twooftheballasttanksweremadeasrollreductiontanks.Oneofthesecouldalsobeusedforfreshwater. Theoutline specifications state thatthereweretobethreerollreductiontanks,butthemidshipstankwasnotbuiltandthespacewasused for other purposes. The outline specificationsalsoindicatedifferenttotaltankcapacities.
Therollreductiontanksareusedtoalterthe vessel’s sailing characteristics. If roll reduction
tanksareusedcorrectly,therollwillbereducedintherelevantwaveperiods.Thepurposeistoimprovecomfortonboardandsecurebetterwork
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Figure 5.2 General arrangement
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Figure 5.3 Tank plan
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ingconditionsforthecrew,forexampleinconnectionwithworkondeck.
Rigchainlockerswereplacedaboutmidships. They have loose hatch covers that are recessedintothevessel’smaindeck.Therigchainlockers
canbefilledwithseawater.
5.4 Stability
5.4.1 The stability book
Thevesselhadanapprovedstabilitybook,includingInstructionsforMaster.
The stability book is prepared so as to describethevessel’sstabilitycharacteristicsandtobeatoolwherebythecrewcancontrolthevessel’s stability in varying load conditions. The
structureofthebookfollowsatemplatethatUlsteinusesforanchor-handlingvessels.
On31May2006theshipyardpreparedapreliminarystabilitybookbasedonestimatedlightshipweight withcentre ofgravity.The heel test was performed on 20 August 2006 and was approved by the Norwegian Maritime Directorateon23August2006.Withthisasabasis,afinalsta
bilitybookwaspreparedon28August2006(confer Annex 1 Section 1.3). The Norwegian MaritimeDirectorateapprovedthevessel’sintactanddamaged stability as supply ship on 2 October2006(conferAnnex1Section1.4).Thecertificate
ofapprovalalsostatesthatthecontentofthestabilitybooksatisfiesIMOResolutionA.469(XII). The NorwegianMaritimeDirectorate hasstatedthatthiswasdoneforthesakeoftherebeingnodoubt, in port state control, which internationalregulatorysystemwasusedfortheapproval.
The stability book includes calculations for anumberofdifferentcategoriesofloadconditions. Theloadconditionsarepreparedforwhatcanberegardedasruleconditionsforsupplyandtowingoperations plus some example conditions of anchor-handling.Thecontentandstructureofthe
rule conditions are laid down in the regulatorysystem.Aruleconditionmay,forexample,combine10%bunkersandmaximumdeckcargo.The variousrule conditionsaredesignedwithaviewto possible critical load conditions being documentedinrelationtostability.Theexampleconditionshaveacontentthatismeanttoembracetypical operations that the vessel can perform. No
Figure 5.4 GM min curve
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specificrequirementsfortheexampleconditionsforanchor-handlinginthestabilitybookarelaiddownbytheregulatorysystem,butitwasagreedthatthevesselwastofulfilIMOResolutionA.469(XII), whichcontainsprovisions onthe prepara
tionof“theworstanticipatedloadconditions”.Itmustthereforebeexpectedthatthestabilitybookcontainssuchconditions.SeeotherwiseSection3.2foramoredetaileddescriptionoftheregulatorysystem.
AsmentionedaboveinSection3.2,thestabilitybookshallalsocontaininformationthatinaquickandsimplemannerenablesthemasterofthevessel to obtainprecise guidanceabout the vessel’strimandstabilityunderdifferentsailingconditions.
The stability book also discusses the use ofrollreductiontanks,thoughnotintheformonin
structions.Thediscussionisgeneralandpointsoutwhatfactorsareimportanttotheuseofthetanks.Inordertofindoutwhetherthetankcanbe
usedforagiventypeofloadconditions,forexampleanchor-handling,onehastoeithermakeone’sowncalculationsorchecktoseewhethereachindividualtypeofloadconditionisinthebookaboutthetankornot.
5.4.2 Control of stability on board
Controlofstabilityonboardisdoneprimarilybythe useofKGmax or GMmin limit curves. Thecurvesandaguidelinefortheiruseappearsinthestabilitybook.
TheKGmaxcurvesshowhowhighthecentreofgravitycanbeoverthevessel’sbaseline(keel). The GMmin curves show how low GM can be.GMisverticaldistancebetweenthevessel’scentre of gravity and her initial roll centre. The
curvesarepreparedforvaryingdraughts.IfKGorGMareontherightsideofthecurves,thevessel’sstabilitywillbesatisfactory.
Figure 5.5 Screen capture from load calculator
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100%loadonthemainenginesthatworkwithconstantRPM. The higher the load on the axlegenerators, the less is left over forbollard pull.Forexample,withmaximumuseofthrustersandmaximumloadonwinchmotors,62%ofmaximum
performancewillbeleftoverforthemainpropellers. The bollard pull is thus reduced from 180tonnestoaslittleas125tonnes.
The vessel’s propulsion system, including theelectricalpowersystem,isofatriedandtesteddesignthathasbeenusedformanyyearsonanchor-handlingvessels.Thismeansthatthevessel’scertifiedbollardpullwillappearmoreasatheoreticalthanasarealreferenceinanchor-handlingoperationswhereheavyuseofthrusterscanbeexpected.
Lowoilpressureinthegearbox,forexampleinheeling,maytrigger autostopon the appurte
nant main engines, associated axle generator,thrusterandmainpropeller.
The vessel is equipped with a dynamic positioning(DP)system,IMOClass2.Thevessel’sinstalledengineandpropulsionsystemisclassedbyDNV.TheDPsystemwasnotinuseatthetimeoftheincident.
SeeotherwisethedetaileddescriptionoftheenginesysteminthereportfromShip&OffshoreSurveyorsAS,Annex1Part8.
5.6 Winches and otheranchor-handling equipment
ThevesselwasequippedwithaRollsRoyce/Brattvågtowingandanchor-handlingwinchofwaterfall type/ BSL400/SL400W-3P. The winch packageconsistsoffollowingunits:– One400tonneAHwinchwithcapacity5,000m
x77mmwire– Two 400 tonne AH /towing winches with
capacity2500mx77mmwire– One 138 tonne secondary winch of type
ALMX3138U with capacity 1,600m x 8” (203mm).
All thewincheswereequippedwithspoolingde viceswithlateralpressurecapacities,respectively60,40and20tonnes.
Figure 5.6 Winch work station – screen capture
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Figure 5.7 Winch layout
Photo: Tony Hall
Figure 5.8 Dimensioned sketch of shark-jaws and towing-pins
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Figure 5.9 Photograph of shark-jaws and towing-pins
Ondelivery from the shipyard the following wirelengthswereinstalled:
AHwinch 1,700mx77mm Towingwinch 1,500mx77mm
Secondarywinch 0
Ontheafterdeck,attheedgebythesternroller, two shark-jaws were installed 1.75 metresfromthecentreline.Eachshark-jawhasacoupleoftowing-pins,oneouterandoneinner,whicharefitted closer to the stern roller than the shark- jaws. It is0.5metresbetweenthecentrelineandtheinneredgeoftheinnertowing-pin,seeFigure5.8.Theinnertowing-pinsareclosertothevessel’s centreline than are the shark-jaws. Theshark-jawcanonlybeusedwhenthechainorwireisrestingagainsttheoutertowing-pin,seeFigure5.9.Diameteroftheshark-jawis500mmandthatofthetowing-pin450mm.Whenthetowing-pinsare raised, the connection is closed, in that theflangesareturnedtowardsoneanother.Whenthetowing-pinsaredepressed,abrakevalveisopenedsoastoreducethehydraulicpressureinthesystem.
Thehydraulicsystemfunctions insuchawaythat if the vessel rolls over and remains upside
down,inconsequenceoftheirownweighttheto wing-pinsandshark-jawwillslideout.Thebrake valveswillhold theshark-jawand towing-pins in
raisedpositionevenifthevesselshouldlaterreturntoanuprightposition,seeAnnex1,Section1.11,foradescriptionfromKarmøyWinch.
Thepowerresourcesfortheanchor-handlingequipmentcamefrom betweenone and fourhy
draulicpumpsthatdeliveredamaximumoilpressureof60bar.Thiscouldgiveliftingcapacityonthefirstwirelayer,withadrumdiameterof1,300mm,ofabout400tonnes.Withmorewireonthedrumsliftingcapacityisreduced.
Maximum brakecapacity is 550 tonnes withthesamequantityofwire.Allthewincheswereequippedwithtensioncontrol,whichisgovernedbyadjustment of the hydraulic motor’s workingpressure.Acontrolpanelgavethewinchoperatorinformationaboutthepowerresources,theconnections,thestatusofbrakesandthetension.SeeFigure5.6.
The winch package has a function for emergencyrelease,conferAnnex1,Section1.7.Themainprincipleofthiswinchistoachieveacontrolled release,where the tension determines at whatspeeditwillgo.Intheeventofapowercut,the accumulators will see to sufficient powerresourcestoensurethefunctionalityofthesystem.
At thetimeof theincident,thewirefromtheanchor-handling winch had been slacked off, in
thattheemergencyreleasebuttonhadbeenacti vated.Thewinch’soperationalstatus wasconsequentlythatconnectionswerein,butthebrakes
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released.Accordingtothemanufacturer,thesystemwouldthenreducethetorquetoaminimumandthedrumwouldincreasespeedonthebasisofexternalstressfromthewireorchain(tension)uptoaspeedofabout40m/min(half-fulldrum).
FirstOfficerSyversenobservedabout12m/min. At thetimeof the incidentthefollowingwirelengthswereinstalled:
AHwinch 2,300mx84mm Towingwinch 1,500mx77mmSecondarywinch 1,700mx77mm
DNVhastestedandcertifiedthewinches,including the emergency release, by delegationfromtheNorwegianMaritimeDirectorateandin
accordancewiththeDirectorate’sregulatorysystem,conferSection3.2.Therequirementisemergencyreleasewithinamaximumof10secondsofactivation. Testswere made for the anchor-handling winch (aft), with brake activated at 105tonnestension(4secondstorelease)andwithoutbrakeactivated68tonnes (1second torelease).Correspondingtestsweredonealsoforthe towing winch (forward starboard) and the working winch(forwardport).
5.7 Rescue equipment and rescuearrangement
Thevesselhadsix inflatablerescue floats, threeoneachside.ThevesselwasalsoequippedwithaManOverBoardboat(MOBboat)topickuppeopleinthewater.Thetotalnumberofsurvivalsuits was39,andthey wereplacedin cabinsanddedicatedworkstationssuchasthebridgeandenginecontrolroom.Thetotalnumberoflife-jacketswas40, which wereplaced in lockers on A Deck atmustering stations plus the bridge and controlroom.Allrescueequipmentwasinstalledandapprovedincompliancewiththeregulations.
5.8 Navigation and communicationsequipment
Thevessel wasequippedwith the followingpermanentnavigationequipment:– Radar3cm
– Radar10cmARPA– DGPSx2– GPScompass
Figure 5.10 Survival suit
– ECDIS
– Gyrocompassplus4xrepeaters– Magneticcompass– Autopilot– Sonar – Anemometer
On board was also “Transocean” positioningequipment of type DGPS for use inanchor-handling. This means that the positions and movement of both the rig and the vessels could bemonitoredwithaprecisionof+/-2m(filedinacomputerfile).Thisequipmentwascentrallyoperated from the rig by the navigation operator.RegistrationfromthissystemisshowninFigure5.11.
The vessel was equipped with the followingpermanentcommunicationequipment:– VHF2permanentlyinstalled– VHFDSC2permanentlyinstalled– MF/HF – MF/HFDSC – MF/HFTelex – InmarsatC
– Satellitetelephone– AIS – Navtex
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Figure 5.11 Image from Navpak during run-out of anchor no. 2
– Facsimile
– PortableVHFx5– SARTx2 – EPIRBx2
Withtheexceptionof thefiveportableVHFs,theotherequipmentwaslocatedonthebridge.TheEPIRB,whichisafloatingradiotransponder,wasmounted on the wheelhouse roof. As far as theCommission knows,nosignals from the EPIRB werereceivedafterthecapsizing,soitwasprobablynotreleasedduringtheaccident.
Allnavigationsandcommunicationequipment wasinstalledandapprovedinconformitywiththeregulatorysystem.
5.9 Manning
The“BourbonDolphin”hadtwoshifts thatwereled by Captains Frank Reiersen and HugoHansen.UndertheNorwegianMaritimeDirectorate’smanningschedule,therewastohavebeensafetymanningofinalltenpersonsoneachshift,
soastomeetthecertificaterequirementsoftheQualification Requirements, confer Section 3.4. This requirementwas fulfilled at the timeof the
accident.Forfurtherdiscussionofthecrews,see
Section4.2.
5.10 Operating history from October2006 until the end of March 2007
The “Bourbon Dolphin” had completed16 workassignmentsoffshorepriortoherloss.Thevesselhadparticipatedinninerigmoveswithanchor-handlinginTheNorthSeaareaoncharterfromboth Norwegian and foreign operators. The“Bourbon Dolphin” had also performed supplyand subsea support assignments.Several of theassignmentsweresolengthythatbothcrewshifts wereinvolved.
Intheperiodfrom4Octoberto7NovemberthevesselwasmannedbyShift1(withCaptainFrankReiersen).Fromandincludingassignmentno.5,towingofa rig forConocoPhillips,Shift1andShift2(withCaptainHugoHansen)alternated.
According to information from the company,the“BourbonDolphin”functionedwellandlived
uptotheexpectationstheownershadofthevessel. Both Captain Frank Reiersen and CaptainHugoHansentestifiedthatthevesselwasanall
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rounderandeffective.Both,however,hadsomequestionsrelatedtocargocapacitiesandthevessel’sstability,asdescribedinSection12.3.2.
AstheCommissionhasunderstoodtheexplanationsonthispoint,themastersattributedthis
tothefactthatthevesselwasnew,andtheyneeded to gain experience with the vessel’s sailingcharacteristicsundervariousconditions.
5.11 Evaluation
5.11.1 Contracting and construction
Thefigures thatcanberelatedtochangesmadeto the A102 design of the “Bourbon Dolphin”pointinthedirectionofheavierequipmentbeingplacedoverthemaindeck.Thisisinlinewithin
formation that the Commission has receivedthroughwitnessquestioning.Thechangeswereofadesignnatureandaffectedthegrosstonnage.
TheCommissionhad,throughitsquestioning,notreceivedtheimpressionthatthevessel’sstability characteristics had been subjected to anyparticularevaluationinthelightofthechangesimplemented.Itisclearthatthesecharacteristics wouldbeaffectedandthusmeantthatthevessel’sstability could be more demanding to deal withduringoperations.
5.11.2 The vessel’s arrangement
The vessel is arranged with many tanks, to beusedforbothballastandcargo.Thismaybecargoofthetypebrine,barite,bentonite,mudetc.Useofsuchtanksforseawatermeansaneedtocleanthembeforeuseforcargo,whichinvolvesacostanduseoftime.Thismayrepresentathresholdforuseofthetanksforseawater,whichisunfortunate.Itoughtnottobethecasethateconomicsandsafetyareopposedtooneanotherin theoperationalassessmentsmadebythecrew.Con versations with the vessel’s crew confirms thatsuchthresholdsexistedandthattheywerereluctanttofillthesetankswithseawater.
IntheCommission’sopinion,ballasttanksthatitisnecessarytouseinordertosafeguardthe vessel’s stability in anchor-handling operations,shouldnotbeofthecombinedtype.
5.11.3 Stability
The vessel’s stability book contains a chaptercalled“InstructionsforMaster”.Thecontentsofthischapterare standardisedandprovide nodi
rectinformationaboutimportantmattersrelatedtothevessel’sstabilityinvariousoperations.Thisis an unfortunate practice that the NorwegianMaritimeDirectorate ought tohave pointed outduringitsapprovalofthestabilitybook.
The company had not prepared instructionsforuseoftherollreductiontanksasrequiredbytheBuildingRegulationsSection15.Itwastherebynotcommunicatedthatthetanksofthe“BourbonDolphin”oughttobeemptyduringanchor-handlingoperations.
The Commission has also noted that thebook’sloadconditionsforanchor-handlingdonotfollow the standard for set-up of conditions thattheshipyardhadusedforothervesselsandalsoconfirmedunderquestioning.Useofwinchpowerandappurtenantpointofattackforthis(against
theinnertowing-pin)isnotcompatiblewiththe vessel’smaximumwinchpowerandtheuseoftheshark-jaw.TheCommissionwouldnotethattherearenoconcreterequirementsforthecontentofsuchloadconditions,butconsidersthatthecircumstancesaroundthisoughttoagreaterextenthavebeencommunicatedinthestabilitybooksoastomakesurethatthecrewwereawareofthisandofthelimitationsitimposed.
TheTechnicalManager,BjørnBergsnes,hadamong other things a background from Ulstein
Design.Hewasthusinapositiontounderstandthe vessel’s technical characteristics, includingthoserelatedtostability.Thiswasalsoamonghisprimarydutiesinthecompany.Therewasadialogue between the company, including FrankReiersenandtheshipyard,aboutthevessel’sloadconditions.FrankReiersenaskedforthepreparation ofmore,andmore realistic, loadconditionsoverandabovewhathadbeenpresentedbytheshipyard.AsfarastheCommissionisaware,thisdialogueceased in September 2006 without further clarification. Given his expertise, Bergsnesoughttohavefollowedthisupandmadesurethattherewasnodoubtthatthecrewobtainedknowledge of the vessel’s stability characteristics andoperationallimitations.
For the “Bourbon Dolphin” the anchor-handlingconditionsweresetupinsuchawaythatbunkershadtoberefilledafterthreeorfourdays.Suchafrequentbunkeringwilloftenbeverydifficulttoachieve.ThemasterstoldtheCommissionthatlargequantitiesofbunkerswerenecessarytosafeguard the vessel’s stability. The anchor-han
dlingconditionsconfirmthis. TheCommissionhasnotedweaknessesinUlstein’s quality assuranceof thevessel’s stability.
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RegulationsNo. 1855of17December 2004(theRescueRegulations)makesafunctionalrequirementthataninflatablefloatshallbedeployedautomaticallyifthevesselshouldsink.
On15November2007CommissionMember
DagAndreassenandCaptainFrankReiersenperformedatestandreviewofarescuefloatsimilarto those used on the “Bourbon Dolphin”. It appearsthatthefloatswereinstalledincompliance withtheregulatorysystem.Theremaybeseveralreasonswhytheywerenotreleasedwhenthevesselsank.Themostprobableisthat,becausethe vessel was floating upside down for three days,the cradle design, deck design or loose objectspreventedthefloatsfromfloatinguptothesurface.Whenthevesselsubsequentlysank,therotationpatternprobablypreventedliberationofthe
floats from structures in the superstructure. As
regardsalaterreleaseofthefloats,itisconsideredthatthesystemwasnolongerintactbecauseofthewaterpressure.SubsequentROVfilesconfirm that one of the floats on port side wassquashedflatonthevessel.Sinceonefloatwas
observed near the casualty, it follows that fourfloatsareunaccountedfor. TheradartransponderwaslaterfoundoffHar
stadinNorthNorway. The Commission is of the opinion that the
footgearofthesurvivalsuitprovideslittlesupportandreducedmobility.Thismayresultindelayingthedonningofthesuitaslongaspossible.Inthisincidentitwasnotobservedthatthesurvivalsuit was used, although life-jackets were. That sevenoffifteensurvivedwearingonlyalife-jacketisduemainlytonearbyvesselshavingcomequicklyto
therescue.
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Chapter 6The planning of the rig move
6.1 Introduction
Drillingrigscaneitherbepositionedonthefieldbytheuseofamooringsystemorelsewiththeaid of dynamic positioning or a combination ofthese. The majority of the rigs operating in the
NorthSeaandadjacentareasaremoored.Manyof these rigs were not designed for deep water. Theexistingmooringlinesmustthenbeextendedwithchain/wire/polyesteroracombinationofthese,andperhapsspringbuoys,sothattherigcanbeanchoredindeepwater.Someoftheserigs(thisdoesnotapplytothe“TransoceanRather”) willnotbeabletobeartheweightofseveralhundred metresof extrachain and lighter mooringsystememployingwireorpolyestermustthenbedesigned. For the same strength, wire weighs
aboutonequarterasmuchaschaininwaterandpolyesterabout1/30thofchain’sweightinwater.Inthelastdecadetheuseofpolyesterhasbecomemorecommonfordrillrigsindeepwater,butitisnotwidespreadintheNorthSeaandisregardedasrelativelynewtechnology.
Whenadrillrigistobemovedfromonelocationtoanother,itmaybeaquestionofanythingfrom one nautical mile to movement over widestretchesofocean.Withtheexceptionofrigswithdynamicpositioning,allrigsmustbeassistedbytowingvesselsandanchor-handlingvesselsinordertomoorthemselves.
Formooring,eithertherig’spermanentsystemisused,wherethemooringisrunoutfromtherig,orelseapre-laidmooringsystem.Inthefirstmethodtheanchorsandthemooringlinesarerunoutandtautenedfromtherig.Inapre-laidsystemtheanchors are first installed in the correct positionandthereafterthemooringlinesarestretcheduptowardstherigwiththeaidofananchor-handling vessel. Useofpre-laid systems isnotcommon intheNorthSeabutisemployedtoanincreasingde
greewherefoundexpedient.Usingapre-laidsystemcanreducetheforcestowhichthevesselsareexposedtoaminimumduringdeploymentofthe
anchors.Duringthedeploymenttheforcesarelimitedmostlytotheweightofthemooringlinebetweenseabedandvessel.Theseforcesareeasytocontrol,astheyaremainlyvertical.
TheRosebankfindwasmadein2004.InApril2007 activity consisted in drilling of appraisal wellstoevaluatethefind.
In the rig move in question, it was the rig“Transocean Rather” that was to be moved twonauticalmiles from 213/26-1z Rosebank– Location“G”toLocation“I”.Thischapterwillprovideadescriptionoftheinvolvedpartiesontheoperatorside,oftherigandthekeypersonnelduringtheoperation,andwilldiscusstheprocedurethat waspreparedfortherigmove.
6.2 Brief description of Chevron,
Transocean and Trident
The oil company Chevron North Sea Limited(Chevron)isapartofChevronUpstreamEurope,the strategic business unit in Chevron Corporation.ChevronCorporationhasitsheadofficeinSanRamon,California, and isoneoftheworld’sbiggestintegratedenergycompanieswithoperations in more than 180 countries all over the world,and involvedineverysectorof theoil andgasindustry.
Chevron UpstreamEurope has a number ofexplorationfieldsintheNorthSeaarea,amongother things in the UK Sector. There, ChevronhasownershipinterestsinfiveproductionfieldsinwhichChevronistheoperator,onefieldincommonoperationandthreefieldsoperatedbyothercompanies.
Chevronhasacomprehensivewrittenmanualfortheimplementationofmarineoperations,the“ChevronTexacoMarineOperationsManual”,see Annex1 Section3.1. Themanual also applies to Trident,whichpreparedtheprocedure.Chevron
hasalsoprepared“GuidancetoVesselMasters”forvesselshiredforChevronbyTEAMMarine,conferSection7.1andAnnex1,Section3.4.
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RichardMacklinwasChevronMarine&HSESpecialistfortheoperation.
Transocean is the world’s biggest offshoredrillingcontractor,andstandsfortheoperationofaround 82 mobile drilling units, which include
drillshipsandvariouskindsofrig.FourteenoftherigsareoperatingintheBritishandNorwegiansectors of Northern Europe. On a world basis Transocean has 30 rigs that can drill in watersdeeperthan1,370metres.
ThecompanyTransoceanis registeredintheCaymanIslands.HeadofficeisinHouston,Texas. ThebusinessunitsforEuropeandAfricaaremanaged from offices in Aberdeen and Paris.Transoceanhasmorethan12,500employees.
ForTransocean’soperationamanualformarine operations has been prepared, the “Tran
soceanMarineOperationsManual”,whichisgeneralandisusedforallTransocean’smobiledrillingunits.
For the “Transocean Rather” there was alsopreparedaseparateOperationManagementPlan(OMP)forthecontractwithChevron,inconformitywiththerequirementsofUKStepChangeinSafety,HealthandSafetyManagementSystemInterfacing. The Emergency Response portion ofthe OMP satisfied the special requirements ofRegulation4oftheOffshoreInstallations(Preven
tion of Fire and Explosion, and Emergency Responses)Regulations1995,conferSection6.6;see Annex1Section3.5.
IntheTransocean datacard,conferAnnex1Section3.6,itisstatedthatthevesselsshalloperateinconformitywiththeNWEAguidelines.
Key personnel on the “Transocean Rather”duringtheoperationarediscussedinSection6.4.
Trident is a British consultancy firm that offersmaritimeandtechnicalservicesandhasmovingofrigsasitsspeciality.Thecompanyhasbeen
inoperationsince1986andperformsmorethan200 rig moves per year worldwide. Trident hasperformed moving of semi-submersible rigs in waterdepthsfrom59to1,650metres.
Trident has amarine, a technical andapositioningdivision,whocollaboratetocreateanintegratedsolutioninwhichalltheservicesaredeliveredbyTrident.Themarinedivisionisresponsible for marine superintendents and towmasters. Tridentdoesnothaveanyemployeesofitsowntodischargethetowmasterfunction,buthiresself-employed individuals on an ad hoc basis. The
technicaldivisionhasemployeeswithnavalarchitect qualifications, whereas the positioning division contributes hydrographical surveyors andnavigationengineers.
SeanJohnsonofTridentwasamarinesuperintendentfortherigmove,whereasMartinKobiela wastechnicalmanager.Duringtheoperation,inspectorMartinTroupofTridentwasstationedonboardtherigassurveyengineer.
6.3 The “Transocean Rather” -specifications
Theoilrig“Transocean”Ratherhasthefollowingspecifications:
Name: Type:GrossTonnage:ClassNotation:
Constructionsite:Constructionyear:PreviousName:
PortofRegistry:Flagstate:Owner:Operator:
Country:
Design: Accommodationsection:Helideck:
TransoceanRatherColumnStabilizedunit22,052DNV+1A1HELDK,DRILL,CRANE,ICE-T
DaewooShipbuilding&HeavyMachineryLtd,Okpo,SouthKorea1987–12,upgradedin1995SonatPratRather1988SonatRather1997PanamaPanama TransoceanOffshoreDeepwaterDrillingInc. TransoceanOffshore(UK)Incwithcompanyaddress TransoceanHouse,CrawpeelRoad,Altens,Aberdeen TheUnitedKingdom
GVA-4500108bunks+2Transoceanoffices,2customeroffices,1sickbay89ftx89ft;Chinook234orSikorskyS-61
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erator about all operational non-conformances. Thetowmastershallkeeparunninglogofdutiesandincidentsduringtheoperationandperformhistasksfromthepilothouse.
The towmasters during the rig move were
RossWatson,JohnG.SapsfordandHarveyWilks.RossWatsoncameonboardon26Marchandlefttherigon9April.JohnSapsfordcameonboardon28March.Duringthefirstphaseoftheoperation,WatsonandWilksfunctionedastowmasters, while Sapsford had the role of Chevron MarineRepresentative,whowastosafeguardtheoperator’sinterestsduringtheoperation.Inadditiontotheirfunctionastowmasters,WilksandSapsford were the Chevron Marine Representative onboardduringthelastphaseoftheoperation.
TheCommissionhasbeeninformedby repre
sentativesoftheoperator,bytheduty-holderandbythetowmastersthatthisarrangementwascommonintheUKSectorandthatitwasnotconsideredthatthecombinationoftherolesofChevronMarineRepresentativeandtowmasterinvolvedanysafetylimitationsorlossofasafetybarrier.
Harvey Wilks was certified as deck officer with10years’offshoreexperienceinthepositionascontrolroomofficerand,inunspecifiedperiods,asreserveOIM.Hewasservingastowmasterforthefirsttimeonthe“TransoceanRather”.
J. G. Sapsford is certified as a ship’s master withanOIMcertificateinaddition.Hehaseleven years’practiceasabargesupervisorandanOIM.From2002hehasbeenmarinerepresentativeindifferentoffshoreprojectsincludingrigmoves.
Navigation Engineer
The navigationengineerhandles the positioningequipmentusedduringtherigmoveandassiststhe vessels with navigation-related questions.MartinAllanTroup,ofTrident,wasondutywhen
theaccidentoccurred. A more detailed description of work assign
mentsandresponsibilitiesduringtherigmoveisprovidedintheRMP(Sections2.3and2.4),see Annex1,Section3.7.
Figur 6.2 The Rosebank Field
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choicewasfirstandforemostnegativeexperiences(lossofbuoyancybuoys)withapre-laysystemfortherigatalocationonthemarginoftheAtlantic.
6.7 The rig move to 213/26-1z Rosebank- Location “G”
TheoriginalplanwastomovetherigfromShell’sBenbeculafieldandmooritonthefirstChevronfield,LocationG.Due,however,totechnicalproblemswithdeparturefromtheShellfield,inAugust2006itwasdecidedtotowtherigtoInvergordoninordertoperformthenecessaryrepairs. ThefirstrigmoveforChevronwas thereforethetowingoftherigfromInvergordontoLocationG, whereitwasmooredon25October2006.Therig
move from Invergordon to Location G took 14days15hours(Annex1,Section3.7).Thevesselsused during this move were the “Highland Val-our”, the “Highland Courage”, the “NormandNeptun”andthe“MærskLeader”.
The procedures for this rig move were preparedbyTrident.
6.8 The planning of the rig move toLocation “I”
AfterthemooringatLocationGcommenced,theplayersbegantheirpreparationsforthemovetoLocationI.Trident’sSeanJohnsontestifiedbeforethe Commission that they gained some experiencefromthemovetoLocationG.Amongotherthingsthechasingsystemdidnotwork,sothattheyhadtouseJ-chasers,seeFigure6.4.BecauseoftheforcesandweightduringdeploymentoftheanchorsatLocationG,therewereproblemswith
thewinchesontherig.Theproblemsthatarose werenotwith the tension,butwith thewinches’dynamic braking system, which was not dimensionedfortheweightof theextrachain.Onthisrigmovetheyburntoutasetofdiscbrakeswhile
running out chain. More information on the winchproblemsduring therigmovetoLocationGwillbefoundinAnnex1,Section3.7.Inordertoreducethewinchloadsontherig,it wasdecidedtouseatwo-boatsolutiontodeployeachoftheanchors.Inadditionfivevesselswerespecified instead of four; one vessel was to beusedasapuretowingandgrapplingvessel.
6.9 Rig Move Procedure for Location “I”
The latest revision of the rig move procedure(RMP)isdated16March2007,seeAnnex1Section3.10.Plannedtimefortherigmovewasfivedayseighthours.
6.9.1 The vessels
Page5oftheRMPsaysthatfiveanchor-handling vessels shall be available for the operation, four“primary”vesselsplusonetowingvessel.
Page16oftheRMPshowsthevesselsnomi
natedasfollows; AHVA–Primaryvessel AHVB–Primaryvessel AHVC–Assistvessel AHVD–Assistvessel AHVE–Towingandgrapplingvessel
Onpage17oftheRMPitisstatedthatallAHVsshallhaveaminimumbollardpullof 180 tonnesandthetowingvesseloneof150tonnes.Inaddition,itisheredefinedwhatkindofequipmenteachofthefouranchor-handlingvesselsshallbeabletotakeonboard.• All the vessels shall have gypsy for 76mm
chain• OneAHVshallhavegypsyfor84mmchain• AJ-chaser• Agrapnel
Itisthereafterdescribedthattheprimaryvesselsmusttakeonboardthefollowingequipment:• One2300m84mmworkwire• Capacityforthree914m76mmchaininserts• Chaingypsiesfor76mmchain
• Capacityfor900m84mmchainFigur 6.4 Lockable J-chaser
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Figur 6.5 Anchor recovery – Stage 6
It is thereafter described that the assist vesselsmusttakeonboardthefollowingequipment:• One2,300m84mmworkwire• Capacityfora914m76mmchaininserts
Itfollowsfromthisthatalsoeachoftheassistvesselsweretorecoveranddeployaprimaryanchorandchaininserts.
The RMP did not make any explicit requirementsforthevessels’winchcapacity.
6.9.2 Recovery of the secondary anchors(nos. 2, 3, 6 and 7)
Recoveryofanchorsisdonebytheanchor-handlingvesselpayingoutworkwireandgoingouttotheanchoralongthechainwiththeaidofaJ-chaser,seeFigure6.4.Theprocedurestatesthatoneshallnotoperatewithmorethan150tonnestensionontheAHVwinchin“breaking”ofanchors withoutthetowmaster’spermission.
Theanchoris“broken”loosefromtheseabed withtheaidofthevessel’swinch.Incaseswhere
thechainhassunkintotheseabed,theAHVliftsthe chain loose from the seabed by using her winch.Thereafter the rig and theAHV winch in
thewireatthesametimeastheAHVfollowsthechainuntilallthewirehasbeenwinchedin.Withthe anchor under the stern roller there is onlychainbetweentherigandthevessel,asshowninFigure6.5.Inordertomakeacontrolleddecouplingofthechaininserts,anassistantanchor-handlingsvesselisusedtotaketheweightofthechainabout300maftoftheprimaryvesselwiththeaidofagrapnel,seeFigure6.6.Thisistofacilitatetheanchor’splacementoverthesternrollerforsubse-
Figur 6.6 Grapnel
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quent uncoupling from the chain.The chain insertsarethenstoredintheprimaryvessel’srigchain locker and the anchor remains lying ondeck.Therigchainisthereafterwinchedinandtheendtransferredtotherigwiththeaidof the
PermanentChaserPennant(PCP).
6.9.3 Recovery of primary anchors (nos. 1, 4,5 and 8), towing to Location “G”
Itwasarequirementoftheprocedurethatallthefourprimaryanchorsbebrokenlooseatthesametime.Whenalloftheanchorshavebeenbrokenloosefromtheseabed,butnot lifted, the towing vesselshallconnectherself totowcablesandassistinholdingtheriginposition.Whenthetowhasbeensecured(i.e.,thetowingvesselconnect
edtotherig),recoveryoftheanchorscanbegin. Whentheanchorsareatthesternroller,seeFigure6.5,thetowcanbegin.Whentherigiswithin50metresofitslocation,thetowingvesselsareuncoupledandmadereadytoassistasgrappling vesselsinthedeploymentofanchors.
6.9.4 Deployment of anchors
AccordingtoRMP,primaryanchorno.4(seeFig
ure6.3)isthefirstanchordeployed.Deploymentoftheanchorsisthereafterapurereversaloftherecovery process described above. The anchorsaredeployedinpairsanddiagonally.Duringdeploymentof the anchors,grappling will proceed
about200metresfromtherig’swinch.Aftertheanchorshavebeenrunout,theyarepre-tautened withtheaidoftherig’swinch.Afterallfourprimaryanchorshavebeendeployed,therigisstabilisedatthelocation.
6.9.5 Requirements for bollard pull
ThecalculationsintheRMPfocusedon:• Tensioninmooringlineandworkwire• Requirementsfortheanchor-handlingvessel’s
bollardpull
• Vesselpositionsinrelationtotherig• Anchorpositionsovertheseabed• Mooringline’sangleswiththefairlead,and• Necessarylengthofworkwire.
In the analyses made for recovery and deploymentofanchor,staticforcesduetotheweightofchainandwirewerecalculated.Tridentthereaftermadesimplifieddynamicanalysesexclusivelyinahead sea for the conditions that resulted in the
Figur 6.7 Anchor recovery – Stage 1
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Figur 6.8 Anchor recovery – Stage 5
Source:copieddirectfromtheRMP.
higheststaticforces.Intheseanalysesthemovements of a typical middle-sized anchor-handling vesselwascalculatedin amaximumwaveof4.0metres(Hsapproximately2.2metres),whichresultedina2.0-metreheavemovement,accordingtotheRMP.Thisheavemovementwasmodelledasaregularmovementattheendofthemooringlinesandtheforceswerethencalculated.Theeffectofneitherthepitchnorthesurgewastakenintoaccountinthesedynamicforcecalculations.
Fortherecoveryanalyses,stage1(seeFigure6.7)resultedinthegreatestforces.Forcesduetothe weight of just the mooring lines were 262tonnes at the vessel’s stern, which resulted in anecessarybollardpullof195.9tonnes.Inadditionto these forces, calculated total external weatherforcesduetowind,currentandwavedriftwerecalculatedat10.9tonnesinaheadseaand48.8tonnesinalateralsea.Thestaticforceswerecalculatedformaximumwavesof4.0mwithaperiodof8.5s,current speed of 1.0m/s and wind speed of 10m/s.
Currentagainstthemooringlineswasnottakenintoaccountinthesecalculations,asconfirmedintheCommission’squestioningofMartinKobiela.
Accordingtothesimplifieddynamiccalculations,onewouldthenseeforcesuptowards318tonnesonthevessel’swinch.
ToquotefromSeanJohnson’stestimonybeforetheCommission:
“Thisisanalternativetaskthatmightberele vant,butthatwasnotnecessary.Theinformationinthecurvesissetupforthesakeofthetowmasters.Theweightofthevesselswasthe
reforemuchlowerinrecoveryofanchors,becausethechaincouldlieontheseabedandnotmuchbollardpullwasrequiredforrecovery. Thevesselsdidnot,therefore,haveanyhighrequirement for bollard pull in this stage. It wasofnosignificancethatthechainwasdraggedalongtheseabed.JohnsonalsoexplainedStage3oftherecoveryofanchors,seep.58oftheprocedures,toReiersen,wherehe(Johnson)thinkstheloadwas136tonnes,whichwasthemaximumbollardpullthatJohnsonexpectedduringthemooringrecoverymethod.”
How this was communicated to Captain FrankReiersen is discussed in more detail in Section8.1.
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Forthedeploymentanalyses,step5(seeFigure 6.8) resulted in the greatest forces. Forcesdue totheweightofjustthemooringlineswere243.6tonnesatthevessel’sstern,whichresultedinanecessarybollardpullof160.2tonnes.Inad
ditiontotheseforces,totalexternalweatherforcesduetowind,currentandwavedriftwerecalculatedat10.9tonnesinaheadseaand48.8tonnesinalateralsea.Thestaticforceswerecalculatedformaximumwavesat4.0mwithaperiodof8.5s,currentspeedof1.0m/sandwindspeedof10m/s.Currentagainstthemooringlineswasnotincludedinthesecalculations.
According to the simplified dynamic calculations,inStage5forcesapproaching292tonnesonthevessel’swinchwouldthenbeseen.
6.9.6 Weather criteria
UnderSection6.5.3 oftheNWEAguidelines foranchor-handling, the rig move procedures shallcontain weather criteria (the worst weather in which the operation can be performed) and weatherwindow(weather forecasts that indicatethattheoperationcanbeperformedwithinagivenperiod),sothatappliedanalysesandthebasisforthesecanbehandledsoastosecureacontrolledoperation.
Chevron’sMarineOperationsManualappliesto Trident, who prepared the procedure. The weathercriteriainthemanualwerethustobefollowedbyTrident.
It appears from the manual’s Section 9.5.1(Mooringandanchoringpatterns)thatarigmoveprocedureshallincludethefollowing:
“Themaximumweatherlimitsforworkingandstand by conditions including maximum expected anchor line tension where required.”(original in English)
Section4.6.3ofthemanual(Vesseldetails)statesfurtherthat:
“Contractorshallasaminimumprovidethefollowing details of all vessels working in thespreadwhenanchoring
1. Theminimumbollardpullnecessarytoholdthevesselatalldraftsagainsttheworstanticipatedtidalstream,40knotwind,anda6metersseaallactinginthesamedirection.Themaximum and minimum bollard pull required
dependingonthedirectionoftheweatherrelativetothevessel.
2. Limitingenvironmentalconditionsforoperating
3. Propulsionandpositioningsystems”(original
in English)
WithreferencetoTable4onpage23oftheRMP,Martin Kobiela testified before the Commissionthat the indicated values are used only in themooringanalysis,butmerelyasa“roughguide”formaximumcriteria.Therearetherebynospecificweathercriteriafortheoperation.TheweatherconditionsreferredtointheRMP’smooringanalysisare:• Maximumwavesof4.0m,withawaveperiodof
8.5s• Currentspeed1.0m/s(1.94knots)• Windspeed10m/s(19.4knots)
Kobiela also testified that those performing theoperation must continuously consider whetherthe weather conditions are satisfactory. This isevaluated there and then by the participants. ThereisnoassessmentintheRMPofhowmuchdowntimeduetotheweatherconditionswasexpectedduringtheoperation.
6.9.7 Risk assessments and plans for
alternative situations (contingencyplanning)
AsdescribedindetailinSection3.7.2, theNWEAguidelinesforanchor-handlingdemandthatriskassessmentsbeperformedfortheoperation.
Section 1.2.2 (Responsibility) of Chevron’sMarineOperationsManuallaysdownthefollowingregardingplansforalternativesituations(contingencyplanning)andriskhandling;
“ChevronTexacohasadutyofcaretoensurethatallworkiscarriedoutwithminimumrisk
toallpersonnelandfacilities.Tothatend,operationalproceduresshallbesubmittedearlysothatpriortoapproval,allpartiescanbeconsultedandasnecessaryariskassessmentcanbeundertakentoidentifypotentialmajorhazardsand demonstrate that adequate proceduresandsafeguardsareinplacetomitigateagainstpotentialhazardsandtheirconsequencespriorto mobilisation. This shall also ensure thatChevronTexaco and the Marine ContractorSafety Management Systems complementeachother”(original in English)
ItisfurtherstatedinSection1.2.3(Clarification):“TomakecleartheChevronTexacopolicyandattitude to standards and responsibilities re
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garding the way in whichmarine operationsareplannedandcarriedoutatanyoftheChevronTexacosites”.(original in English)
Section4.6.5(Contingencyplans)statesthat:
“Theoffshoreunit/vesseloperatorshallsubmitastepbystepcontingencyplan.Actionsandlistingshowingtheresponsibilitiesintheeventofanemergencywhichshallincludebutnotbelimitedtothefollowing:[…]suddendeteriorationinweather”(original in English)
Section 4.12.1.6 (Information required) has thefollowingtosay:
“TheContractorwillberequiredtosubmitthefollowinginformationtoChevronTexacoforre
view:- […]HAZOPdocumentationandsafetyplan”(original in English)
Identified scenarios that according to the RMPcandemandplanningofalternativesituationsare:• Problems reaching the anchor by use of J-
chaser• PCPfractureneartherig• FractureofPCPduringdeploymentofanchor
wire.
TheriskassessmentsintheRMPcoveronlyhan
dlingoftechnicalproblemsthatcanbeexpectedto arise during recovery and deployment of anchors.Riskassessmentsrelatedtothesafetyoftherigsandthevesselsarenotdiscussed.
6.10 Evaluation
IntheCommission’sopinion,thereexistseveral weaknessesintheplanningoftherigmove.Keyelements are composition of the maritime manningontherig,choiceofmooringsystemandinstallation method, method of calculating necessarybollardpullandwinchcapacitypluslackofconcordancebetweenestimatedandactualweather.ThebiggestandmostseriousweaknessintheRMPisneverthelessthefundamentallackofriskanalysesandidentification(HAZID)andthehandling of unforeseen events (contingency planning).
6.10.1 Maritime manning on the
“Transocean Rather”Section6.1oftheNWEAdemandsthatrigpersonnelmustknowtheparticipantvessels’operational
limitations.TheOIM’sformalandpracticalexpertiseinmaritimeoperationswaslimited,whichis whythefollow-upoperationalauthority wasdelegated to the towmaster hired for the rig move. Thetowmasteriswithoutaffiliationwiththepar
ticipantorganisations. Thebargesuper visorwasthememberof thepermanentrigcrewwiththegreatestmaritimeexpertiseandduringtherigmoveprovidesperipheral maritime assessment support to the OIM.Duringtherigmovehehadtheprimaryresponsibilityforwinchandballastoperations.Overallresponsibility for handling safety is vested in theOIM.Thetowmaster,whoinpracticeledthemaritimeoperationonbehalfoftheOIM,hadnotparticipatedinthepreparationoftheRMPincludingriskassessments.Thishelpedtoremoveorweak
ennecessarysafetybarriersofahumancharacter.Totheextentthatthemaritimeexpertiseisnotlocatedonthehighestlevelofcommand,itisessentialthattherebecloseandgoodcommunicationbetweenthepossessorofthatmaritimeexpertiseand theperson insupremecommandonboard the rig throughout the rig move. In theplanningphase,ahighlevelofmaritimeexpertiseisrequiredtohandlesafety.
O’MalleyclaimedtotheCommissionthathe was not informed about important non-conform
ances during the operation – the drift from therun-outlineforanchornos.6and2,grapplingoutside the RMP and the near-miss between the“Bourbon Dolphin” and the “Highland Valour”. TheCommissioncannotseethatasystemwasestablished or implemented that secured an adequateflowofinformation.ItisthedutyoftheOIMatalltimestobeinformedaboutallmattersofsignificance for the operation beingperformable inconformitywiththeRMPandinsuchawaythatthesafetyofallinvolvedpartiesisaddressed.
Chevron’s Marine Representative is charged withaddressingthelevelofoperationalsafetyenshrinedinChevron’sMarineManual.
Inaddition,thedoubling-upoftherolesoftow-masterandChevron’sMarineRepresentativeremovedanimportantsafetybarrierfortheoperation.
6.10.2 Choice of mooring system andinstallation method
Intheplanningphasenoqualitativeanalysesofal
ternative mooring technology (wire/polyester/springbuoys)andalternativeinstallationmethods(prelayingofanchors)wereperformed.Useofal
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ternativescouldhavesecuredamorerobustinstallation methodology, and less vulnerability to weatherrisk.InoperationalareaswithgreatchallengesasregardsbothweatheranddepthssuchastheareawestofShetland,itwillalwaysbea
material contribution to safety management tomake a thorough evaluation of all alternatives withregardtochoiceofmaterialsanddeploymentmethods.
6.10.3 The rig move procedure
6.10.3.1 Requirements for bollard pull
TheRMPidentifiesrequirementsforbollardpullduetotheweightofthemooringlinesaloneas160.2tonnesduringdeploymentofanchor.Inadditiontothis,theRMPestimates10.9tonnesin
staticforcesonthevesselinaheadseaand48.8tonnesinalateralseawith4mmaxwaves,1m/scurrentand10m/swind.
Duringdeploymentoftheanchorstherewillbeaprobabilitythatsomeofthevesselswillhavetodeploythemooringlineinalateralseaand/oraheadsea.Inthecaseofthe“BourbonDolphin”,wehaveheardtestimonythattheuseoffullsidethrustreducesthebollardpullto125tonnes(seeSection5.5foramoredetailedexplanation).Thisreduction willvaryfromvesseltovessel,butsuchareduction
isnotunusualforamedium-sizedanchor-handling vessels.Inadditiontothis,thebollardpullwillbehighlyreducedduetothevessel’smovementinthe waves,thereductionofthebollardpullwillnaturallyincreasewithdeterioratingweather.
TheRMPreferstothefactthatthestaticforcesonthevesselarecalculatedtotakeaccountofforthereductioninbollardpull.TheCommissioncannot see how this is taken account of in theRMP and has made repeated requests for a detailedexplanation.AfterthehearingtheCommission received two reports from Martin Kobiela.He was not successful in justifying the requirement for 180 tonnes bollard pull; see Annex 1,Sections3.14and3.15.
Incalculatingtheexpectedstaticforcesinalateralsea,theRMPdoesnotincludeforcesactingonthevesselduetocurrentagainstthemooringlines.Ina1.0m/suniformcurrentfordeploymentofanchorstage5,forcesactingontheAHVduetocurrentforcesagainstthelineshavebeencalculatedasupto20tonnes.SuchaloadmeansthattheRMPhasunderestimatedthestaticforces
byaround35%.Increasingwind,wavesandcurrent will yield markedly increasing static forces(windandcurrent forcesareproportional tothe
square of the speed). The weather criteria employedintheaboveanalysesarenotreflectedintheRMPasoperationallimitationsandareconsequentlynotareference-pointforsafeoperations.
Giventhenavigationaldata,theCommission
is able to note that the “Bourbon Dolphin” wasdriftingbeforetheweatherfrom13:45,whichindicatesthatshedidnothavesufficientthrustercapacitytokeepherselfalongthedeploymentline. The probable cause of the drifting around thistime is thought to be increasing current forcesacrossthemooringlinesduetoincreasingchainlengthsplusageneraldeteriorationintheweathersituation.
TheCommissionalsofinds itrelevanttorefertocalculationsofnecessarybollardpullinaheadseashownintheRMP.Asmentionedabove,the
static forces from the weight of chain and wirealonecometo160.2tonnes.Inaddition,accountmustbetakenof10.9tonnesinstaticforcespluscurrent forces against the mooring lines, whichtheCommissionestimatesat3tonnes.Exclusivelystaticforceswilltherebydemandaminimumof174tonnesincontinuousbollardpull.Thestaticforcesare calculated ina weather situation that wasconsiderablymilderthantherealoneat thetimeoftheaccident.Asmentionedabove,inaddition the effective bollard pull is severely weak
ened due to the vessel’s movements. The 180tonnesbollardpullstandardisthereforetoolow. TheCommissionalsofindsweaknessesinthe
calculationsoftensiontobefoundintheRMP.AsmentionedaboveinSection6.9.5,onlysimplifieddynamic calculations were made. The Commissionhasperformeditsowncalculationsthatconfirm the static loads on themooring line in theRMP. A maximum winch tension of 292 tonnes was calculated for deploymentof anchors in theRMP.Theseanalyseshavebeencalculatedwitha4mmaxwave(significantwaveheight,Hs,approx2.15m). If we take account of the vessel’s realmovement, theseforceswill increasebyan estimated 10-15%, depending on the vessel’s movementcharacteristics.AsKobielamentionsinhisreporttotheCommission(Annex1Section3.15),itisnormaltosetHsfrom3.5to4.0mforanchor-handling. Corresponding analyses in a 4.0m Hs wouldhavegivenanestimatedincreaseof25%.Innormalpracticeforaddressingsafetyfactorsone wouldhaveusedadesigncriterionofHs5.0mforanoperationalcriterionof4.0mHs(explainedin
greaterdetailinSection3.8).Correspondinganal yseswithHs5.0mwouldhaveyieldedanestimatedincreaseof30%.
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Such an underestimate of forces could havecausedanoverloadofthevessel’swinchcapacity.
6.10.3.2 Weather criteria
IntheopinionoftheCommission,itmeritscriticismthattheRMPwasnotinconformitywiththerequirementsofNWEAplus internalChevronrequirements(40knotswindand6metrewaves)asregardsweathercriteria.ThisisdescribedingreaterdetailinSections3.7and6.9.6.ClearweathercriteriashallbeestablishedinanRMP.ItisexpectedthatweathercriteriaareunambiguouslycommunicatedintheRMPasanimportantsafetybarrier. Theforcesappearingin theanalyseswere incompleteanddefectiveandunsuitedtovisualisingtheforcesone could expect toencounterduring the
operation.Thishadsignificanceforbothrequirementsforbollardpullandforwinchforces.
ItappearedfromtheRMPthat,beforetheoperation was implemented, weather forecasts wouldbeobtainedandaweatherwindowidentified in order to execute the operation in a safemanner.TheCommissionwouldquestionwhetheritispossibletoidentifysuchaweatherwindow whilelackingclearrequirementsforweathercriteria. Both Chevron’s and Trident’s representativeshavetoldtheCommissionthatclearweather
criteria can be unfortunate and counter-productive.Chevron’s marine manual, however, makesunambiguousrequirementsforclearweathercriteria.
The Commission is of the opinion thatmaximumweathercriteriacanhardlybeanobstacletosafeoperationbutonthecontraryamaterialelement of the risk analyses. The weather criteriacanbehandledasareferenceforsuspensionofthe operation in an unfortunate combination of waves,windandcurrent. All RMPs ought todefinethatthestatedweathercriterionisanupperlimitforsafeoperationandbecontinuouslyevaluatedbythepersonresponsiblefortheoperation.
6.10.3.3 Risk assessments and plans for alternative
operations (contingency planning).
Chevron lays down in its system of proceduresthattheiroperationsaretobeplannedandexecuted with minimal risk. The operator has arguedthattheRMPisacoherentriskanalysisinwhichtherisksarecontinuouslyhandledforallstages.
In the Commission’s opinion the procedurelacksanintegratedandcomprehensiveriskanalysisfortheoperationasawhole,despitesuchare
quirement being enshrined in Chevron’s and Transocean’s operational manuals. In addition,the NWEA guidelines contain provisions aboutthis. The RMP lacks formal HAZIDs and HAZ-OPs,andbyandlargelackssolutionsforalterna
tiveoperations(contingencyplanning). AsdescribedinSection3.6.2,itistheCommission’sopinionthatunderBritishactsandregulationstheemployerhastheresponsibilityforpre ventingpeopleotherthanhisemployeesbeingexposed to risk, as long as this is “reasonablypracticable”.
Witnesses from theoperatorandrig testifiedbeforetheCommissionthattheydidnotregarditas foreseeable that an anchor-handling vesselcould roll over, and consequently that no riskmeasuresforsuchascenariowereprepared.Giv
enthatcapsizinghasformanyyearsbeenafrequentcauseofaccidentsatsea,theCommissioncanbynomeansconcurinsuchreasoning.Thattherehasbeenonlyasinglecapsizeofananchor-handling vessel does not mean that we can deducethatsuchvesselsareincapableofcapsizing.IntheCommission’sopinion,therefore,“reasonablypracticable”measurescouldinasimplemannerbeentakentominimisetherisk,byforexampleanattentionzonearoundanchorrun-outlines,seeSection13.9.3.
Moreover,witnessesfromtheoperatorandrighavearguedthatitisthevesselsthemselvesthatmustaddress theirownsafety.To this theCommission would remark that even if the vesselsought to have prepared adequate risk assessments, this does not relieve the operator of hisparamountresponsibilityforaddressingthesafetyofallinvolvedparties.
ItfollowsfromChevron’smarinemanualandtheNWEAguidelinesthattheoperatormustensurethatriskanalysesconcerningtheparticipating vessels are prepared before the operationstarts. Neither during the start-up meeting onshoreoronarrivalonthefielddidtherigaskforthevessels’internalriskanalyses.ThiswasconfirmedbyCaptainsReiersenandBergtunduringquestioning.Reiersenalsotestifiedthatnormallythevesselssendtheirriskassessmentstotherig.FromwhattheCommissionhasbeengiventounderstand,itisnotusualforthevesselstosendtheriskanalysestothecompany.
There has been a failure to consider whatmightgowrongbetweenvesselandrigandbe
tweenparticipantvessels.Inordertoreducethetensionontherig,itwasdecidedtouseatwo-boatsolutionintheanchor-handlingoperation.Useof
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twovesselsneartooneanotherincreasestheriskfortheinvolvedparties.Handlingofgreatforcesbetween two vessels may unleash uncontrolledforcesagainsttheonevesselintheeventofunforeseeneventssuchawirebreakingoragrapnel
being lost. Itmay also causeuncontrollednear-misssituations,aswasexperiencedshortlybeforetheaccident.Thatthevesselswereoperatinginatough weather and current environment withgreatmooringweightsincreasedtheriskpicturefurther. If, instead, a lighter mooring system orpresetting of anchors had been considered, theriskcouldhavebeenreducedconsiderably.
Transocean’s system of procedures demandsthatspecialriskanalyses(HAZOP)beundertaken in multi-vessel operations. The Commissionperceivesthisasapplicabletorigmoves.Sucha
multi-vesselriskanalysisistotallyabsentfromtheRMP.
NorhadtheRMPperformedriskanalysesforthecasethatavesseldidnotfollowtherun-out
line as shown on the navigation plot. At suchdepths and such heavy-weather areas to whichtheRMPapplied,theriskanalysisshouldalsoinclude the consequences of an anchor being deployedinthewrongposition.
InadditiontheCommissionnotestheinsufficientalternativeoperationalsolutions(contingencyplanning).Chevron’smarinemanualcontainscomprehensive requirements for contingencyplanning.Overandabovethethreeconcretecases discussed in Section 6.9.7, contingency planningisabsentfromtheRMP.Requirementsintheoperating systems of the participant operators werenotreflectedintheRMP.EvenifTridenthadpreparedaRMP, itwas ChevronMarine HE&S,Richard Macklin, who was supposed to ensurethattheoperationalrequirementsintheChevron
marineoperationsmanualwereconformedtointheplanningandexecutionoftheoperation.
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Chapter 7The vessels
spot market before the operation was to start.7.1 The chartering of the Spotcontractsforvesselsarenormal:theship-
anchor-handling vessels brokerpreparesandtransmitslistsofavailable vessels thatmeettheoperator’svesselspecifica-
Under the contract between Chevron and the tions.Onthebasisoftheshipbroker’slistofves“Transocean Rather”, Chevron was responsible sel specifications and price offers, the vesselsfor acquiring sufficient vessels to move and arechosen–oftenshortlybeforetherigmoveis
moortherig.Thevesselswerehiredfromthe tobegin.
Figure 7.1 The “Bourbon Dolphin” specifications
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On the basis of expected loads, chain weights
and lengths of workwire etc., Trident had prepa-
red vessel specifications for Chevron. A minimum
bollard pull of 180 tonnes and winch capacity of
400 tonnes was recommended. In preparatory
meetings, in which also TEAM Marine and theshipbrokers, the Stewart Group, participated, the
involved parties reviewed the vessel specificati-
ons.
TEAM Marine is a logistics organisation that,
under the coordination agreement between Chev-
ron and other oil companies, operates to achieve
coordination and efficiency in the hire market and
use of offshore supply and service vessels in the
North Sea area. TEAM Marine is not a separate
legal entity, does not have employees of its own
and does not sign contracts in its own name.
TEAM Marine collaborates closely with theStewart Group, whose mission is to find available
vessels that meet the requirements from TEAM
Marine’s members, and to broker contracts with
the companies. The Stewart Group operated on
the basis of a shortlist of available vessels that met
requirements for winch capacity, brake capacity,
rig chain locker capacity and bollard pull for this
concrete rig move.
In the sales prospectus the “Bourbon Dolphin”
was described as a DP anchor handling tug supply
vessel, 194 tonne bollard pull, 400 tonne line pull winch, see Figure 7.1, and was marketed by the
company as a deepwater anchorhandling vessel.
In the Ulstein Group’s website of February 2007,
the vessel was described as designed to handle
Table 7.1 Overview table of involved vessels
anchors and mooring lines in deep water. On 26
March the “Bourbon Dolphin” was inspected by
the Stewart Group’s maritime inspectors in Aber-
deen and accepted. At the same time the “Olym-
pic Hercules” was chartered for the assignment.
Because of winch repairs on the rig there was noneed for four vessels from the outset.
The contract between Chevron and Bourbon
Ships was signed on 26 March 2007. The hire pe-
riod was stated as “Day by day hire for the Trans-
ocean Rather rig move” with a rate of GBP
50,000 per day excluding fuel. In connection with
the chartering the vessel was visited by Sean
Johnson of Trident, who on behalf of Chevron in-
troduced the RMP on board, see Section 8.1. In
the Transmittal Form (Trident Offshore Limi-
ted) signed by Captain Frank Reiersen, the ves-
sel was designated “AHV C”, see Annex 1, Secti-on 3.11.
A week later the “Highland Valour” and the
“Vidar Viking” were chartered for the assign-
ment.
7.2 Overview table with key data
The table below shows the five vessels involved in
the operation of moving the “Transocean Rather”.
Sections 7.3 to 7.5 provide a more detailed de-scription of the vessels. The towing vessel “Sea
Lynx”, which in the Rig Move Procedure was as-
signed the role of Vessel E (tug), had a peripheral
role in the accident and is not described further.
Bourbon Highland Olympic
Dolphin Valour Hercules Vidar Viking Sea Lynx
Gross Tonnage (t) 2,974 3,160 4,477 3,382 2,556
BP continuous (t) 180 180 250 205 173
LOA (m) 75.2 80 82.1 83.7 73.5
B (m) 17 18 20 18 16.4
Winch pullingpower (mt) 400 500 500 400 300
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7.3 The “Highland Valour”
The anchor-handling vessel “Highland Valour”hasthefollowingspecifications;
Name: HighlandValour Type: 630–SupplyVessel/TugGrossTonnage: 3,160ClassNotation: ICE-CTugSupplyVesselSFE0CLEANDK(+)HL(2.8)Constructedat: AkerTulecaSAOutfittingYard: SøviknesShipyardASConstructionyear: 2003-07PortofRegistry: LondonFlagstate: TheUnitedKingdomOwner: GulfOffshore(NS)LtdOperator: GulfOffshore(NS)Ltd Address: 184-192MarketStreet,Aberdeen
Country: UnitedKingdom
Technical DataBollardPullcont.: 180tonnes Winchpulling-power: 500tonnesLengthoverall: 80mBeam: 18mDepth: 8mDraught: 6.6mNetweight: 1,187tonnesDeadweight: 2,989tonnes
Figure 7.2 The “Highland Valour”
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Themasterofthe“HighlandValour”wasGor- experienceatsea,firstandforemostfromvariousdonKeithWilliams,whohasalmost30years’ex- offshorevessels.FirstOfficerSeanMarkAlexanperience of anchor-handling. Chief Officer John derDicksonhastwoyearsexperienceofanchor-HughDunlophasover20yearsexperienceatsea, handling.AllthesewerequestionedbytheComof which the last twelve from anchor-handling. mission.
ChiefEngineerRichardStuartOgleyhas25years
7.4 The “Olympic Hercules”
The anchor-handling vessel “Olympic Hercules”hasthefollowingspecifications;
Name: OlympicHercules Type: 630–SupplyVessel/TugGrossTonnage: 4,477ClassNotation: ICE-CTugSupplyVesselOILRECSFE0DYNPOS-AUTRDK(+)HL(2.5)
Constructedat: UlsteinVerftASOutfittingYard: UlsteinVerftASConstructionyear: 2002-01PortofRegistry: ÅlesundFlagstate: NorwayOwner: OlympicShipASOperator: OlympicShippingAS Address: P.O.Box234,FosnavågCountry: Norway
Technical DataBollardPullcont.: 250tonnes Winchpulling-power: 500tonnes
Lengthoverall: 82.1mBeam: 20mDepth: 9.6mDraught: 7.5mNetweight: 1,343tonnesDeadweight: 3,750tonnes
The master of the “Olympic Hercules” was asmasterand3½yearsasChiefOfficer.BergtunGrimAreBergtun.Hehaseightyearsexperience testifiedbeforetheCommission.ofanchor-handling,ofwhichinteralia1¾years
Figure 7.3 The “Olympic Hercules”
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7.5 The “Vidar Viking”
The anchor-handling vessel “Vidar Viking” hasthefollowingspecifications;
Name: VidarViking Type: 630–SupplyVessel/TugGrossTonnage: 3,382ClassNotation: ICE-10IcebreakerTugSupplyVesselSFHELDK-SHE0DYNPOS-AUTR
NAUT-OCDK(+)HL(2.8)Constructedat: HavyardLeir vikA.SOutfittingYard: HavyardLeir vikA.SConstructionyear: 2001-02PortofRegistry: SkärhamnFlagstate: SwedenOwner: TransvikingIcebreaking&OffshoreASOperator: CompanyABTransatlantic
Address: Box32Country: Sweden
Technical DataBollardPullcont.: 205tonnes Winchpulling-power: 400tonnesLengthoverall: 83.7mBeam: 18mDepth: 8.6mDraught: 7.2mNetweight: 1,145tonnesDeadweight: 2,600tonnes
Themasterof the“Vidar Viking” wasHalvor anchor-handlingasmaster.Enoksentestifiedbe-MagnusEnoksen.Hehasfiveyearsexperiencein foretheCommission.
Figure 7.4 The “Vidar Viking”
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7.6 Evaluation of vessel inspection
National and international requirements includetechnical vessel specifications, crew qualificati
ons, operational routines and system management.Inthelightofthecomplexityoftheoperation
inquestionandsafetysensitivity,vesselrequirementsmustbeverifiedthrough,invaryingdegrees,submitteddocumentationandlocalvesselreview (inspection). Direct contact with the ownermayincertaincasesberequiredinordertoverifyimplementationofoperatingsystems.Thisapplies
forexampletoownerqualificationrequirementsandroutines.
Inspectionrevealedalackofvesselinformationtoverifyfactorssuchas:• Availablebollardpullwithfulluseofthrusters
• Maximum manageable lateral current undergivenconditions• Crewqualifications• Systemimplementation(riskanalyses)• Basic operational procedures (anchor-hand
ling)• Hydrostaticcharacteristics.
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Chapter 8Execution of the rig move
8.1 The briefing meeting
As mentionedaboveinSection3.7.2, theNWEAguidelineslaydownthattherigownerisresponsiblefortherigmoveproceduresbeingreviewed withparticipantvesselsandkeypersonnel,thein
formationbeingunderstoodandtheriskassessmentbeingperformed.
Before the assignment commenced, all the vesselshad individualbriefings inAberdeenwithSeanJohnsonofTrident.AtthebriefingthevesselsreceivedtheRMP,handedoverbyJohnsonpersonally.TheywerealsogivenChevron’sGuidancetoVesselMasters,conferAnnex1Section3.4. Present at the briefing on the “BourbonDolphin”wereJohnson,CaptainFrankReiersen,theChiefOfficer,andtheFirstOfficer.Theme
etinglastedaboutonehour,whichseveralwitnessestestifiedisanormaltimeintheUKSector.AccordingtoCaptainBergtun,onthe“OlympicHercules”thebriefinglastedabout20minutes.
AtthebriefingtheRMPwasgonethrough.It wasnotreviewedindetail,buttheywentthroughtheintroductionandgeneralelements.AccordingtoJohnson,theydiscussedthedrawingsintheprocedure and looked more closely at the mooringsystem,therigsystem,wireetc.Theyalsorevie wedtheseabedconditions,obstaclesandwhattheproceduremeantforthevessels.Reiersentestifiedthatbeforethebriefinghewasnotawareatwhatdepthstheywouldbeoperating,buthedidknowthattheoperationwastoproceedwestofShetland.
Reiersen and Johnson have given divergenttestimonyaboutwhatwassaidatthebriefingwithregardtowhatrolethe“BourbonDolphin”wastoplay in the operation. According to Reiersen, it was said that expected forces could come up to194 tonnes during anchor recovery. Reiersenclaims to have objected at that point that the“Dolphin”didnothavethecapacityforthat,given
itsbollardpullof180tonnes.Inthelightoftheinformation from Johnson, Reiersen understoodthatthe“BourbonDolphin”wasonlytobeanas
sist vessel. By that Reiersen meant that the“Dolphin”shouldonlygrapple.
Forhispart,Johnsontestifiedthatitwasal ways theplan that the“Dolphin” should recoveranddeployasingleprimaryanchorandthatReiersenwasalsoexpresslymadeawarethatchangescouldbemadealongtheway,whichwasalsothe
reason why Johnson went so carefully throughboththerecoveryanddeploymentoftheanchors. Johnson’stestimonyonthis isreproducedunderSection6.9.5.AccordingtoJohnson,therewasnoobjectionfromReiersentothebriefing.
AfterthebriefingwithSeanJohnson,CaptainReiersensummonedthebridgeanddeckcrewonthe“BourbonDolphin”forareviewoftheoperation.ReiersentestifiedbeforetheCommissionthatthe engineers were not called in, because meetingsaremostconcernedwiththedetailsofthe
useoftheanchor-handlingequipment. Atthebriefingswiththeof ficersonthe“HighlandValour”,the“OlympicHercules”andthe“VidarViking”,theyweretoldthattheywouldhavetoexpectchangesalongtheway,withoutitbeingclarifiedwhatthesechangesmightinvolve.ChiefOfficerDunlopofthe“HighlandValour”testifiedthat they were told to “expect the unexpected”. According toRichard Macklin(Chevron), it wasstatedatthemeetingswiththe“Valour”andthe“Viking”thatthevessels’rolescouldbechangedalongtheway.
8.2 The crew change
On30March2007therewasacrewchangeinScalloway,Shetland,wherebyCaptainFrankReiersenandhiscrewwererelievedbyCaptainOdd-neRemøy.Remøywasnottheregularmasteronboard, but had exchanged tours with CaptainHugoHansen.Therestbelongedtotheordinarycrewofthe“BourbonDolphin”.AbleSeamanØy
stein Sjursen had come on board with CaptainFrankReiersen’sshift,butstayedonbecausethemusteringcrewwereamanshort.
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w/o/w”(Stand-by,waitingonweather).TheCommissionhasobtaineddailyreportsfromthecompany.Thelast,whichwassentonthemorningof12April,concerned11April2007.Thecompanydidnotreceiveareportfor12April,norwasone
created. Thedailyreportsformthebasisformodellingofthevessel’sloadconditionatthetimeoftheaccidents,seeTable9.2.
8.3.2 The implementation
The“BourbonDolphin”andthe“OlympicHercules”arrivedonthefieldon27March2007andbegan the work of recovering the secondary anchors.With the “Olympic Hercules” asprimary vesselandthe“BourbonDolphin”asassistvessel,
anchornos.6 and2wererecovered.The“BourbonDolphin”leftthefieldontheeveningof29March for the crew change. On 30 March the“BourbonDolphin”was back and recovered anchorno.3withthe“OlympicHercules”asassist vessel.
On 31 March the “Bourbon Dolphin” begantheworkofbreakinglooseanchorno.7,butwasnotbyherselfabletoloosenthisfromtheseabed. The“OlympicHercules”hadtherefore tobecalledin,andwiththeaidofaJ-chasertheytriedto
get the anchor loose. The anchor came up, butboth the J-chaserand othermooring equipment wasdamaged.
On 2 April the two anchor-handling vesselsandthetug“SeaLynx”arrivedonthefield.Alltheanchor-handlingvesselsparticipatedintheworkoflooseningandrecoveringthefourprimaryanchors.Transcriptsoftherig’slogsshowthatintheperiodfrom2to4Apriltheyhadvariousproblems getting the anchors loose, among otherthingstheybrokeseveralJ-chasers.Recoveryofanchorno.8wasextremelydifficult,equipment was damaged and tension on the rig’s anchor winchreached360tonnes.
During this part of the operation they werealsohamperedbypoorweather.Notuntil8April werealltheanchorsup,anddidtheweatherconditionsallowtherigtobetowedtoandmooredatanewlocation.Recoveryoftheprimaryanchors wasnotdoneinconformitywiththeRMP,butinaccordance with a formal revision made on 30Marchandthetowmaster’sadjustmentsmadeon7April2007.Fordeploymentoftheprimaryan
chorstwovesselshadtobeused,amongotherthingstorelievetheweightontherig’swinches.From9to11Apriltherewasalsoabreakinthe
operationduetotheweather.Allprimaryanchorshadthenbeendeployed.
In his Vessel Performance Assessment tow-masterRossWatson,whowasontherigupto9 April,awardedallthevesselsthegradeVG(very
good).Inthereport(SectionA–Semi-submersibleMarinereport)Watsonwrotethefollowing:
“OlympicHerculesandVidarVikinggoodvessels and crew but – the previous extremelysharpedgeofoperationsinthepastisnolongerthere.
BourbonDolphinisnotsufficientlyexperiencedforthistypeofwork.Thedutypersonsonthebridgehavetobeinstructedfromtherigpilot house and from other vessels in taskssuchashowtoworkchasercollarsandhowtogetagrapneloffthechain.Inthelattercase,at
no.4,theanchorchainhadtobehauledtothedeckforthegrapneltoberemoved.Thatwasafter3hoursofattemptstofreeitandsimplyshouldnothavehappenwithatballastedgrapnel.
HighlandValourisnotnecessarilythefastestinoperationsbutispositiveandsuccessful. Also,thevesselisnotDPequippedyetturnsinajobasgoodasifnotbetterthantheothersonthisoperation.
SeaLynxabsolutelyoutstandingreconnectingthesecondarytowingbridlefollowingthe
breakoftheprimarybridle.”(original in Eng lish)
Therepor tstatedfurtherthatduringrecoveryofthe anchors equipment was damaged, amongother things several J-chasers, swivels and pearlinks.Anchorno.4disappearedontheseabed.
When he testified before the Commission,RossWatsonclarifiedhisdescriptionofthelackofexperienceofthe“BourbonDolphin”asapplicabletotheuseofchasersandotherequipmentinadeepwateroperation.
8.3.3 Written division of labour fordeployment of secondary anchors
While they were waiting for better weather, the“Highland Valour”, the “Bourbon Dolphin” andthe“VidarViking”weresenttoLerwickinorderto supplement damaged equipment, redistributeanchors and fetchother equipment. The “Bourbon Dolphin” then took on board two 18-tonneBruceanchors(secondaryanchors).
First Officer Geir Tore Syversen testified –bothinthemaritimeinquiryandsubsequentlybefore the Commission – that the “Bourbon
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Dolphin”hadaGMof0.26whensheleftLerwick. tedto thefactthattheyhadtogoonstand-byinHesaidhehadenteredthisin thevessel’sdeck expectationofthedeploymentofanchorno.7.log. The Commission has considered this infor- At thesametime,the“Highland Valour”andmationinSection9.10.2.On10Apriltowmaster the “Olympic Hercules” were busy with the de- JohnSapsfordpreparedawrittenprocedurethat ploymentof anchorno.7.The“HighlandValour”
specifiedthevessels’assignmentsand the sequ- alsohadtoomuchloadonthechain,asshownbyenceforrunningoutthefoursecondaryanchors, the log and the fact that at 13:20 the “Olympic which still remained. This was sent by e-mail to Hercules” had to use a J-chaser to relieve theChevron,TridentandTransoceanandtotheves- weight.Itappearsfrom thetestimonyfrom Capsels. The procedure was approved by Chevron. tain Williams and Chief Engineer Ogley of the Therewerenochanges. “HighlandValour”,however,thattheydid notre-
On the morning of 11 April the “Bourbon gisteranyextraordinaryweights. OgleythoughtDolphin”beganthe deployment ofanchor no. 3 thatthetensiononthevessel’swinchwasaroundandgraduallydevelopedproblemswiththechain. 120tonnes.Problemsalsoarosewiththerig’sno.Intherigmovelogsheetisenteredfor11:44: 7winch,whichatonepointhadtobestoppedbe
“ToomuchweightonBourbonDolphingypsy causeofoverheating.Notuntil03:00on12April
whilstpayingoutchainfromlocker,requestVi-
wasanchorno.7ontheseabed.
darVikinggrapplechaintotakeweight”. (ori- On12Aprilthereremaineddeploymentofan ginal in English) chorsnos.6and2.Accordingtotheplanfromthe
towmaster, the “Olympic Hercules” was then to According to the procedure, the “Vidar Viking” deployno.6withthe“HighlandValour”asgrapp wastograpplechain300metresbehindthestern lingvessel,whereasthe“BourbonDolphin”wasof the “Bourbon Dolphin” so as to relieve the todeployno.2withthe“VidarViking”asgrapp weight.The“BourbonDolphin”wasthentoover- lingvessel.boardtheanchorsoverherstern,afterwhichthe At 05:35 the same morning, however, the“VidarViking”wastoloosenhergrapplinghook “HighlandValour”reportedaleakinafuellineandthereaftertograppleanew,300metresfrom andaskedfor1½hourstorepairit.Theyreportedtherig’sfairlead. thecompletionoftherepairat06:56.
Itappearsthatthe“VidarViking”grappledthe The“OlympicHercules”hadcommencedthechainat12:05.Notuntil20:52wastheanchorde- workonanchorno.6at02:40.Sinceat06:00theyployed onthe seabed. Alltogether, the workon hadreachedthestageintheprocesswhengrappthe mooring of no. 3 took over 23 hours up to lingshouldbeinitiated,the“VidarViking”wasas08:13on12April.Thetimecanpartlybeattribu- kedtoassist.
Recovery of anchors:28March anchorno.6 BourbonDolphinassistedOlympicHercules30March anchorno.2 BourbonDolphinassistedOlympicHercules31March anchorno.3 BourbonDolphinrecoveredanchorwithOlympicHercules
asassistvessel1April anchorno.7 Bourbon Dolphin recovered anchor with Olympic Hercules
asassistvessel6April anchorno.8 BourbonDolphinassistedVidarViking7April anchorno.4 BourbonDolphinassistedOlympicHercules7April anchorno.1 BourbonDolphinassistedHighlandValour8April anchorno.5 OlympicHerculesassistedVidarViking
Deployment of anchors:8April anchorno.5 OlympicHerculesassistedVidarViking8April anchorno.1 BourbonDolphinassistedHighlandValour9April anchorno.4 BourbonDolphinassistedOlympicHercules9April anchorno.8 VidarVikingassistedOlympicHercules11April anchorno.3 BourbonDolphindeployedanchorwithVidarVikingas
assistvessel12April anchorno.7 OlympicHerculesassistedHighlandValour12April anchorno.6 VidarVikingassistedOlympicHercules12April anchorno.2 Valourasassistvessel
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The“BourbonDolphin”begantheworkonanchorno.2at09:17.The“VidarViking”wasalreadyatthattimeinvolvedintheworkonanchorno.6.Itwasthereforethe“HighlandValour”thatwaseventually giventhe assignment ofassisting the
“BourbonDolphin”.
8.3.4 The role of the “Bourbon Dolphin” up to12 April
UndertherequirementspecificationsintheRMP,thevesselsshouldhavecapacitytotake914metresof76mmchaininserts.Theprocedurepresupposedthatallthefouranchor-handlingvesselsshould recover and deploy one primary anchoreach. All the chain inserts were of the samelength,regardlessofwhethertheywereforthe
primaryorsecondaryanchors. The“BourbonDolphin”wasinvolvedinreco
veryanddeploymentofallthefoursecondaryanchors,bothasprimaryvesselandasassistvessel. That the vessel was designatedas “Vessel C” inthecharterdoesnotmeananyrestrictionsontheassignmentsthevesselwasgivenduringtheoperation. Nor did the reservations expressed byRossWatsoninhisassessmentleadtoanychanges in the work assigned to the “BourbonDolphin”.
As far as the Commission knows, no objectionsweremadebythe“BourbonDolphin”totheassignmentsthevesselwasgiventoperformduringtheoperation.
8.4 Evaluation
8.4.1 The briefing meeting
The time earmarked for the briefing (about 1hour)is,fromwhattheCommissionhasbeengi vento understand,normalin theUKSector.Theoperationinquestionwas,however,complexanddemanding,andthereforeoccasionedamorethoroughreview thanotherwise,particularly inthelightoftherisksandchallengesthevesselsweretohandle.Johnsonhadhadaroleintheplanningphaseandwasawareoftheprocedure’smorecriticalelements,buthadnooperationalresponsibilityfortheimplementation.
FrankReiersenand Sean Johnson had differentperceptionsofwhatwassaidatthemeeting with regard to the duties of the “Bourbon
Dolphin” and what changes in the procedure
mightinvolve. Theambiguities intheRMP withregardtothevessels’concreteassignments(conferSection6.9),weretherebynotclarifiedviathebriefing.Thereisreasontobelievethatthemisunderstandings were due partly to the fact that
theprocedurewasnotcirculatedpriortothebriefingandpartlythatthetimeallocatedwasinsufficient.AsfarastheCommissionisaware,nominuteswerekept.
Therewasno jointplanningmeetingbetweentheoperator,therigandinvolvedvesselsbeforetheoperationcommenced.Suchameetingwouldhavebeenusefulandprovidedabetterunderstandingoftheoperation.Theyweretoproceedwithacomplicatedoperationindeepwater,whichinteraliainvolvedtandemoperationswiththevessels. Areviewofhazardfactors,experiencesfromthe
previous rig move, weather and current conditionsandcoordinationof technicalchallengesrelated to the operation, would have been naturalitemsontheagendaofsuchameeting.
UndertheNWEAguidelines,priortotheoperationastart-upmeetingshouldbeheld.Theguidelinesdonotsayanythingmoreaboutwhoistobepresent.In61AoftheNorwegianOLFguidelines,however,itisrecommendedthatoperationalpersonnelfromtherig,theoperatorandthevesselsshouldmeet,butthisisneverthelessapracti
cethat isnotalwaysfollowedontheNorwegianShelf.
8.4.2 The crew change
As regards the crew change, questions may beraisedabouttheexpediencyofthechangehappening just after the operation had begun, ratherthan before the operation commenced. At thesame time, it may be difficult to alter dates forcrew changes, which follow shift plans and areplannedwellinadvance,atshortnotice.Thetimeallocatedtothecrewchangewasinlinewithcompanypractice.Seeninrelationtothecomplexityoftheoperation,moretimeshouldprobablyhavebeenallocatedtothehandoveralone.Thegreatestobjectionisneverthelessthatthetimeallocatedwasusedforbothhandoverandfamiliarisationatthesametime(asregardsRemøyandSyversen). For more discussion of this see Section4.7.1.
Due to the time of the crew change (in themiddleofthenight)itwashardtoholdaninternal
briefingwiththecrewbeforedeparture.
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Chapter 9The accident
hadconnectedtheanchortothewireandover9.1 Introduction boardeditoverhersternroller.Theplotfromthe
rigshowsthatatthatpointintimethe“Olympic The rig was moved to Location “I” and the four Hercules”haddriftedeastofmooringline6.primary anchors deployed in the period 8 to 9 CaptainGrimBergtun’stestimonyonthisto April2007.Whentheprimaryanchorshavebeen theCommissionwasasfollows:deployed,therigissafelymoored.Deploymentof
thesecondaryanchors,whichthevesselshaveonboard,isthendonediagonallyandinpairs,soastoavoidone-sidedstressontherig’smooring,as
“Theynoticedduringtherunning-outofchainthattherewasstrongcurrentandhadtobearupalotinordertoholdtheline.Whentheanchorwasconnectedthevesselhadtocorrect
showninthemooringpattern,seeFigure6.3.The vessels proceed in a line as straight as possible
itscourserelativetotheanchortogettheanchoroverthesternroller.Thevesselthenim
fromtherigtothedeploymentposition,alongso-called “anchor tracks”, and so that the deploy-
mediatelydriftedtoportandendedup400metresoffcoursebeforetheanchorwasoverthe
mentiscoordinatedintime.Diagonaldeploymentalsomakesthemooringsufficientlytaut.Seethe
roller. They came increasinglyout of courseandatmaximumhaddrifted600-650metres.
generalaccountinChapter6. Thischapterwill firstpresentthedeployment
Theythenusedalltheirthrustercapacity,butitwasnotsufficienttoholdtheirbowsintothe
ofanchorno.6andthereafteracoherentpresen weather.”
tationoftheeventsonboardthe“BourbonDol- Theworkofrunningoutrigchainandthevessels’phin”inchronologicalsequence.Asapartofthis chain inserts proceeded until 06:00. The “Vidarcourse of events, the grappling attempt and the Viking”, which was free, was then instructed bynear-miss situation with the “Highland Valour” the rig toassist the“OlympicHercules” ingrap willalsobedescribed. plingthechain,astheanchorwaslaunched.Ac-
Thepresentationisbasedonthetestimonyof cording to the rig’s log, the “Vidar Viking” gottheofficersandcrewsofthevessels,andthetow- holdofthechainat07:44.masterandpersonnelonthe“TransoceanRath- The “Olympic Hercules” did not manage toer”.Thetestimoniesareincorporatedinaspecial getbackontrackusingherthrustersandrudder/annextothereport,(seeAnnex2).Writtenlogs, propelleralone. Atthe worst,the“OlympicHer-rigplotsandweatherdataarealsoused. cules”haddriftedabout730metreseastofline
In Section 9.10 the load conditions/stability no. 6. According to Captain Grim Bergtun, thechallenges of the “Bourbon Dolphin” up to the currentwasnormally2.5knots,butthatdaywascapsizingarediscussedspecially. stronger.
Therigfirstaskedthe“OlympicHercules” to wait, while the “Bourbon Dolphin” deployed an
9.2 Anchor no. 6 chorno.2togetherwiththe“HighlandValour”. The “OlympicHercules” used her lateral thrust-
At 02:42 the “Olympic Hercules” fetched PCP ersonfull(80%),butwasstilldriftingoff,andsofromtherigandbegantheworkofrunningout CaptainBergtundidnotwanttoheavetoandwait.therigchaintowardsthepositionofanchorno.6. Bergtunaskedtherigtopayoutitswiresoasto The heading was 160 degrees, but the current givethe“OlympicHercules”speedformanoeu
wasrunninginthedirectionnor-nor-easttonorth vring. The towmaster at first refused, but latereasterlyanditwasnecessarytobearupsoasto grantedtherequest,andwirewaspaidoutfromkeep position. At 06:55 the “Olympic Hercules” therig’swinch.
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Figure 9.1 Trackplot for deployment of anchor no. 6
JamesSutherland,bargemasterontherig,testified before the Commission that running out wirefromtherig’swinchwithoutthechainhavingbeengrappledinvolvesadangerofdamagingthe wireandtherig’sbolster.
Whentherig slacked off thewire, thevesselobtainedpropulsioninthewaterandcouldmakeuseofherrudder.Bygivingstarboardrudderandfullspeedaheadanduselateralthrusters,Bergtunmanaged to manoeuvre the “Olympic Hercules”back against the current and up to the line. Hetestifiedthatthevessel,duetotheweightofthechain and the manoeuvring, then listed up to 12degrees tostarboard.Accordingto the testimonythechainshiftedbetweentheoutertowing-pins.
The“VidarViking”wentof fthechainat11:19. At12:30anchorno.6wasdeployedontheseabedin the correct position. The “Vidar Viking” wasthenallowedtoleavethefield.
9.3 Anchor no. 2
The“BourbonDolphin”hadbeenprimaryvesselinthedeploymentofsecondaryanchorno.3.On
12Aprilthereremainedthedeploymentofthelastsecondary anchor, anchor no. 2.This was a 18tonne Bruce anchor, which the “Bourbon Dolphin”hadtakenonboardinLerwickon9April. Theanchorwasondeck,lashed tothecargorailonportside,asshowninFigure9.3.
Inthetowmaster’splanthelastphaseoftheoperationdescribedasfollows:
“Whenpennantreturnedfromno.6,rigtransfer crane pump from Port to Stbd. Bourbon
Dolphintono.2,receivepennantfromrigandrollerchasercompletewiththrashchain.Rigpayout920mrigchainthenchangeoverto wire. Bourbon Dolphin connect lockered 76mminsertchainanddeploy914mofchainandinstall new roller chaser collar onchain andconnectanchortochain.250tShackleonchasercollartobesecuredwithstainlesssteellockingpins.Thrashchaintobesecuredto250tshacklewithno7PearLink.75mpennanttobesecuredtothrashchainwithkenterorno.7Pearlinkandsecondnew75mpennanttobesecuredtofirstpennantwithCCL,kenterorPearlink.VidarVikingtograpplechain300mfrom stern of Bourbon Dolphin and take weightofchain.BourbonDolphintooverboard
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anchor.VidarVikingtodisengagegrappleandgrapplechain300mfromfairlead.Runanchor.”(original in English)
9.4 The morning shift
OnThursday12April2007CaptainOddneRemøy wentonwatchat06:00.TogetherwithhimonthebridgewasFirstOfficerKjetilRuneVåge.ChiefEngineerFrankNygaardwasonwatchintheengine-room. Also on watch were Able SeamenSandø and Vike. Electrician Søren Kroer, cook ÅnjeNilsenandtheengineeringtraineesThomas Arnesen and Kim Henrik Brandal began their watchesat08:00.
Vågehadtheresponsibilityforpreparingdaily
reports and sending these electronically to thecompany every morning. The Commission hasobtainedthereportsfromthecompany.Thereisnoreportfor12April;thereasonforthisisthatthe daily report concerned the preceding 24hours.Thereportthatwassentinthemorningof12Aprilthusconcerned11April,from00:00to24:00.
9.5 Weather, wind and current
conditions on 12 April 2007
The “Transocean Rather” received and retransmitted to the vessels continuous weather forecasts from two different forecasting institutions, WilkensandWeathernews.
At06:00onThursday12Apriltheforecastwasfor increasing wind from the south-west, with a28-knotmeanspeedandgustingupto35knots(10mheight)until21:00.Waveheightwasgivenas 3.4m significant, max 5.9m, according to theforecast from Wilkens,whoalsoexpected anincreaseto4.0msignificant,max7.1mfrom12:00to21:00,conferAnnex4.4.
Weathernews had a rather milder weatherforecastinwhichthemaxwaveon12Aprilwaspredictedat6.3m,withlesserwindspeedsupto25knots(10m),seeAnnex4.5.
The Commission has received an expert assessmentfromtheNorwegianMeteorologicalInstitute(DNMI)regardingtheweatherconditionsonthedayoftheaccident.DNMI’swavemodelcalculated a significant wave height of 4.0m at
15:00 for the site of the accident (60:59’20’’N,003:49’20’’W).Awavebuoy,lyingabout27nautical miles in a south-westerly direction from the
site of the accident (60:42’02’’N, 004:30’00’’W)measured significant wave heights of 3.0m at15:00,of3.6mat17:00,4.7mat19:00and4.2mat21:00.DNMI’smodelcalculatedarathergreatersignificantwaveheightforthemeasurementloca
tion. On this basis, DNMI estimated the waveheightasbetween3–3.5mat15:00,alittleover3.5mat17:00and4.0mat20:00.DNMIexplainsthatthecurrentintheseareascanreachspeedsofupto3knots,conferAnnex4.3.AlltimesarestatedasCoordinatedUniversalTime(UTC).
Captain Grim Bergtun of the “Olympic Hercules”testifiedthatthewindwasaround30knots. Thecurrentwasnormally2.5knotsbutstrongerthatday,thecurrentdirectionnorth-easterly,afterawhileinamoreeasterlydirection.Bergtunestimatedsignificantwaveheightas3–3.5minthe
periodthe“OlympicHercules”wasworkingwithanchorno.6.
CaptainHalvorEnoksenonthe“VidarViking”testifiedthatthecurrentwasrunninginanortheasterlydirectionandstruckthevesselsontheirstarboardsideswhiletheywereworkingwithanchorno.6.Thewindincreasedinthecourseoftheday,12April,buttheweatherandcurrentconditions were acceptable. Enoksen estimated thecurrentas1–2knotsor0.5–1.0m/sandbetween2-3metressignificantwaveheight
GeirToreSyversentestifieditwasblowingat32knotsfromthesouth-west.Hethoughtsignificantwaveheightwasgivenas2.9metresinthe weather forecast they received from the rig. Hethoughtthatthecurrentwaspossibly2knots(1m/s)buthadnomeasurementtoreferto.
AbleSeamanEgil Hafsås,whowasonwatchfrom12:00,hasinboththemaritimeinquiryandin his testimony before the Commission describedtheweatherconditionsas“borderline”inrelationtowhatwasdefensibleforworkondeck.
AbleSeamanØysteinSjursentestifiedthatthe working conditions were acceptableon 12 April. Able Seaman Per Jan Vike testified before theCommissionthathewentoffwatchat12:00butdidnotregisteranythingabnormal.Theweather wasgoodwhentheytookthechainon theboat,andtheyweretoldthattheweatherwasdeteriorating, but this turned out not to be the case. Therewasnoseaoverthestern.
TheDailyMarineRepor tsentbythe“TransoceanRather”(conferAnnex4.6),for12Aprilreportsawindspeedof37knotsat15:00,max
wavesof5.0mat04:00andof3.5mat15:00.Therig only had instruments for measuring the wind.
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InOctober2007Aerospacepreparedareportshowing that current speed was 0.60 knots at17:00 UTC. Wind was estimated at 26-28 knots(10m height) at 210 degrees. Significant waveheightisestimatedat3-3.5mwitha7-8secondpe
riodat15:00UTC.Maxwaveiscalculatedattwicethesignificantwaveheight.Theseareestimated weatherconditions at17:00,seeAnnex1Section4.9.
Onboardthe“HighlandValour”theyestimatedawindspeedof35knotsat15:00,thewaveheightwascharacterisedas“moderate”to“moderate/rough”onthedayoftheaccident.Captain Williams confirmed that,eventhoughtheconditionswerebeginningtobemarginal,theythoughtitwaspossibletoperformtheoperation.Nooneonboardwassayingthattheoperationshouldbe
suspended.Onboardthestandbyvessel“VikingVictory”
theyestimatedawindspeedof35knotsat16:00and a significant wave height of 2.5m at 08:00, whichwasreducedto2.0mat16:00.
Giventhisinformationabouttheweathersituation, the Commission finds that mean windstrength was 30-35 knots, and significant waveheightwasabout3.5m(maxwavearound7m)atthe time of the accident. The weather observationsarerelativelyconsistentonthis.Ontheoth
erhand, thereis strongdisagreementaboutthecurrent speed, nobody had a currentmeterbutestimatesvariedfrom0.6knots(0.3m/s)upto3knots(1.5m/s).On12Aprilitwascloudy,stable weatherwithgoodvisibility,asshownalsobythepictures.
9.6 Running of chain for anchor no. 2
Thedistancefrom therig to theanchor location wasabout3,000metresasthecrowflies.
Theintentionwastorunoutanchornos.6and2moreorlesssimultaneously.Diagonaltensionloadontherigviachain/rigwinchonno.2wasalsonecessaryinordertogetasufficientlytautmooringofno.6,whichwasbeingrunout.
The“BourbonDolphin”commencedtheworkat09:16/09:20,whenthevesselgotPCPfromtherig. The “Bourbon Dolphin” connected the rigchaintoherownwinchonboard.Therigthenranoutanchorchainfromitswinch,atthesametimeasthe“BourbonDolphin”wasrunningoutalong
the line in a northerly/north-westerly direction. The “Bourbon Dolphin” had anchors on deck,lashedtothecargo-railontheportside.Aswillbe
seenbelow,theCommissionfindsthatthechainendfromtherigwentinoverthesternrolleraftbetween the outer and inner starboard towing-pins.Therig’schainwasrunoutat100metresperminutefromtherigwinch.
At 12:00 therewasachangeofwatchon the“BourbonDolphin”.CaptainRemøywasrelievedby Chief Officer Bjarte Grimstad. First OfficerGeir Tore Syversen relieved First Officer KjetilRune Våge. According to Syversen, the watchchangeonthebridgetook10-15minutes.Theincomingcrewsweregiveninformationabouthowmuch chain had been run from the rig, about weather status and which vessel was to grapplethechaininconnectionwiththeanchordeployment.Able Seamen Hafsås and Sjursen relievedSandøandVike.Thetraineeshadabreakpause
from12:00to13:00.Itappearsfromtherig’slogthatthe“Bourbon
Dolphin”hadhadsomeminordeviationsinbothdirectionsfromthemooringlineinthefirstperiodoftherun-out.
By12:15therig’schain–914metresof84mmchain–hadbeenrunout.Onboardthe“BourbonDolphin”therig’schainwasconnectedto76mmchaininsertsfromthevessel’sstarboardrigchainlockerandcontinuedtorunthechainabout12:53.Plotfromtherigshowsthatatthatpointintime
the“BourbonDolphin”hadnoappreciabledrift. Thechainwasrunoutat20-25metresperminute. The“BourbonDolphin” wasmaintaininga speedofabout0.25knots,astowmasterJohnSapsfordtestified.
Deviations from the line could be read offfrom thenavigationscreenonthebridge,asdescribedinSection5.8.
Fromdataobtainedfromtherig’snavigationsystemitappearsthatthe“BourbonDolphin”wasnot holding on track. At 13:45 itwas registeredthatthe“BourbonDolphin”,whichwasthen1,000metresfromtherig,haddriftedeastofthemooring line. At 14:00 the “Bourbon Dolphin” was1,116.9metresfromtherigand84.2metresofftrack.At14:17thedistancefromtherighadincreased to 1,200 metres and the drift had increasedto185metresfromtheline.
InthemaritimeinquirySyversenhadstatedthat when the “Bourbon Dolphin” had run outabout 3-400 metres of chain inserts, they weretoldtotakeabreak“inordertocorrectinrelationtotherig”.Syversenalsotestifiedthattheywaited
for2-3minutes.Ithasnotbeenpossibletoverifythisthroughotherwitnesstestimony.Accordingtotestimonyfromtowmasterandfromtheofficer
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ofthewatchonthe“HighlandValour”itisfoundthatthe“BourbonDolphin”reportedthat,atthispointintime,14:30,theywerehavingproblemsgettingbacktotherun-outlineandaskedthetow-masterforassistancefromthe“HighlandValour”.
The propulsion engines, steering power andcapacityofthe“BourbonDolphin”aredescribedingreaterdetailinSection5.5,andintheexpert witnesses’ report from Ship & Offshore SurveyorsAS,conferAnnex1Part8.
On12Aprilthelateralthrusterswererunatfullpower.Intheengine-roomtheywereafraidofoverheating. According to testimony from engineering trainee Kim Henrik Brandal, the ChiefEngineerstayedintheengine-roomaftertheendofhiswatchat12:00.Around13:00Brandalwastoldthatthelateralthrusterhadoverheated.Both
the engineers were then in the engine-room. AshorttimebeforetheaccidentBrandalwasagainintheengine-roomand saw thatFirstEngineeringOfficerEmblemwastryingtocooldownthethrusterwithahigh-pressuregun.
FirstOfficerSyversenregisteredveryintenseuse of thrusters as early as when he came on watchat12:00.Currentandwindwerethencomingfromthesamedirection.AccordingtoSyversen,around15:00atelephonecamefromtheFirstEngineeringOfficeraskingforthrustercapacity
tobereduced,buttheChiefOfficerrefusedthis. At the same time the “Bourbon Dolphin” askedtherigforassistancefromthe“HighlandValour”.
ThomasArnesentestifiedthatatonepointheoverheard communication between the engine-roomandthebridge.TheChiefEngineerwas,according to Arnesen, irritated that the bridge wouldnoteaseoffonthethrusters.TheCommissionfindsthatthiswas intheperiodafter13:00,probablythesameoccasionasmentionedinSy versen’stestimony.
The information about the engine use of the“BourbonDolphin”wasnotcommunicatedontotherig.
Accordingtotherig’slog,at14:45the “Bourbon Dolphin” reported that all chain was out(1,817metres).Giventheregistereddata,therefore,itmustbefoundthatthe“BourbonDolphin”hadcontinuedrunningoutchainalsointheperiodfrom13:50to14:45withtheexceptionofthebriefpausementionedabove.
The looseendof thevessel’schainhadbeenconnectedtotheworkwireonboard.Thetimeof
thisoperation,whichwasperformedondeck,hasnot been unambiguously determined. Able SeamanEgilHafsåsdidnotgiveanytimeforthis,but
mostprobablyitwasdonebefore14:30asAbleSeaman Øystein Sjursen testified. This point intimeiscompatiblewiththefactthattherig’slogfor 14:45 says the following: “Bourbon Dolphincompletepayingoutchain”.(all log entries origi
nally in English) According to Syversen’s testimony, all thechainhadnotbeenrunoutuntil16:30.Thistimeisnotcompatiblewiththeassertionthatatthatpointin timetheyhadfailedbothtograpple thechainandtogetthevesselbacktothemooringline.Underwaterphotographstakenofthe“BourbonDolphin”aftertheaccidentshowthatthevesselhadaround220metresofwireconnectedtothechain,paidout.Thiswirelengthmay,however,haverunoutafterthecapsizing,beforewaterpenetration stopped the machinery. This is be
causethetechnicaldesignpermitsrun-outofwireafterablack-out.
9.7 The attempt of the “HighlandValour” to get hold of the chain
Intherig’slogfor14:30iswritten:“HighlandValourtograppleNo2Chain”.Atthispointintimethe“BourbonDolphin”was1,184metresfromtherigand337metresofftherun-outline.The“Bour
bon Dolphin” had then warned the rig that the vessel wanted assistance due to manoeuvringproblems.Measuredinastraightlinethedistancebetween the “BourbonDolphin”and the anchorpositionwas1,968metres.
Grappling of chain at this stage is not dealt with intheRMP.Noris it inconformitywiththeprocedurefordeploymentofanchorno.2thatthetowmasterindicatedinhise-mailof10April.
Whentherequest forassistancewasgrantedbytherig,theobject,accordingtothetowmaster, wasthatthe“HighlandValour”shouldrelievethe“BourbonDolphin”oftheweightofthechain,sothatthe“BourbonDolphin”couldgetherselfbacktothelineforanchorno.2.
TowmasterJohn Sapsford testified that grapplingwasdoneinordertohelpthe“BourbonDolphin” get back to the line. Grappling is routineduringarigmove.Thecrewofthe“HighlandValour” were experienced, and the measure wasconsidered to be in conformity with the proceduresfollowedtogettheanchordeployedinthecorrectposition.The“BourbonDolphin”hadall
chainoutanditremainedonlytoconnecttheanchorandoverboarditoverthesternroller.Atthisstage,the“HighlandValour”wastohaveassisted
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withthegrapnelregardless.The towmastercompliedwiththevessel’swishandassumedthatthe vesselherselfhadevaluatedthesituation.
The Commission would remark that at thispointintimeanchorno.6wasontheseabedand
therigtherebymooredby7ofthe8anchors. At15:00the“HighlandValour”wasrightoverthemooringlineandreadytograpple.The“BourbonDolphin”wasthen559metresofftherun-outlineandherdistancefromtheanchordeploymentpositionhadincreasedto2,016metes.
The“HighlandValour” succeededathersecond grappling attempt. According to testimonyfromRichardOgley,whowasrunningthewinch,the “Highland Valour” went in from the east,asternofthe“BourbonDolphin”,andfirsttried with1,000metresofwireonthehook,butdidnot
achievecontact.CaptainWilliamsandChiefOfficerDunlophavetestifiedthattherigaskedthem tostartgrapplingat900metres,butthattheychose1,000 metres to be on the safe side. They thensankthehookto700metresandtriedagain.The“HighlandValour”thenachievedcontactwiththe
chain and managed to fasten the hook. ChiefOfficerDunlop,whotoldtheCommissionthathehad had long experience with grappling operationsindeepwater,butnotwiththeobjectofhelpinganothervesseltorecoveritsposition.
Therighadregisteredthatthe“BourbonDolphin” had at this point in time run out all herchain.Inadditiontheywereawareofthedistancebetweenthe“BourbonDolphin”andtherig.Therig could thereby have calculated the chain arcand the chain tension, and directed the grappleoperation.TheCommissionisuncertainwhethertherighadatthispointanydefiniteopinionaboutthechain’sangleofattackandhowsharplythechainwentintothedeepafterthe“BourbonDolphin”.
The“BourbonDolphin”continuedtodrift fur
therandfurtheroff-line,atthesametimeasshe was making little headway. From 15:30 to 16:00thedistancefromtherighadincreasedbyalittleover 30 metres, whereas her drifting had increasedfrom650metresto730metres,thatis,anadditional80metresfromtheline.
Figure 9.2 The near-miss
Photo:SeanDickson
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At 16:10 the “Highland Valour” reported thattheyhadsucceededingrapplingthechain.The“HighlandValour”experiencedpowerfultensiononherwinch,at thesametimeasthe“BourbonDolphin”registeredafallintension.At16:20the
following was entered in the towmaster’s log:“BothAHV’sunabletoholdstation.”Atthatpointin time the “Bourbon Dolphin” was 840 metresoff-lineandthedistancefromtheanchordeploymentpositionhadincreasedto1,970metres.
9.8 The near-miss between the“Bourbon Dolphin” and the“Highland Valour”
Thegrapplingoperationwasnotsuccessful.Even
ifthe“HighlandValour”hadholdofthechainabout240maftofthe“BourbonDolphin”,theoperation to get the “Bourbon” Dolphin back into theright position was a failure. The vessels wereeventually lying almost sideways-on with theirsterns closest. The crews of the “Highland Valour”andthe“BourbonDolphin”havegivendetailed testimony about the near-miss that occurredat16:26.Eyewitnessesestimatedthedistancebetween the vessels as a mere few metres, asshownbyphotographstakenfromonboardthe
“HighlandValour”,seeFigure9.2.FirstOfficerSyversen,whowasonthebridgeofthe“BourbonDolphin”withaviewastern,saidin the maritime inquiry that the “Highland Valour”,whenshelostholdofthechain,driftedathighspeedtowardsthe“BourbonDolphin”,andthatacollisionappearedunavoidable.Inhissubsequent testimony before the Commission, heamended this and said that it was probably the“BourbonDolphin” that drifted asternwhen the“HighlandValour”lostthechain.
ChiefOfficerJohnHughDunlopandCaptainGordon Keith Williams, who were both on thebridgeofthe“HighlandValour”,havetestifiedthatthe“BourbonDolphin”driftedtowardsthe“HighlandValour”stern-first.Atthatpoint,accordingtothewitnesses,the“HighlandValour”stillhadholdof the chain. It was not, therefore, the sudden weight of thechainthatcaused thespeedof the“BourbonDolphins”astern.Theythinkthattheylosttheirgriponthechainataratherlaterpointintime.Thesewitnessessupposedthatthe“BourbonDolphin”had lostpropulsionatsomepoint.They
testifiedbeforetheCommissionthatitwasnotuntilaftertheirevasivemanoeuvrethatthe“Highland Valour”losthergriponthechain.
Figure 9.3 The “Bourbon Dolphin” at 16:31
Photo:SeanDickson
Onthebasisofplotsofthevessels’manoeu
vring it is not possible to be sure of when the“HighlandValour”lostholdofthechain.AccordingtotheRigLogSheet,the“HighlandValour”reported“GrappleisoffNo2chain”at16:35.Sy versentestifiedthat thesternwardsdriftcameasa direct result of the “Highland Valour” havinglostholdofthechain.Itisclearthatbothvesselsmovedasternandthatonepointtheywerelyingmoreorlesssidebyside.Thedistancebetweentheirsternswassosmallthat,accordingtoeye witnesses, “the crews could almost haveshakenhands”.
Thankstoquickthinkingonbothvessels,thecollisionwasaverted.The“HighlandValour”manoeuvredaway,whilethe“BourbonDolphin”succeededingoingfullahead.
Thequestionfromthe“HighlandValour”asto whether they should make further attempts tograpplewasansweredbytheriginthenegative. The “Bourbon Dolphin” had drifted so far thatfurtherattemptstograppleinvolved,accordingtothetowmaster’stestimony,ariskofcontactingthemooringlineforanchorno.3.For16:40thelog
reads: “Both vessels instructed to move West –awayfromNo3”.The“HighlandValour”thereafter proceededwestwardsand away from line 2,
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andlayabout500metresoffinexpectationoffurtherinstructions.
Thenear-misswasnotreportedtotherigbyanyofthevesselsandwasthereforenotlogged,neitherbythetowmasternorinotherlogsonthe
rig. Towmaster Sapsford testified that, from hispositioninthepilothouse,hehadbeenunabletoseehowclosethevesselshadbeen.
Ithasbeenstatedthatneitherthecommandingofficerontherig,OIMPatrickO’Malley,norBargemaster James Sutherland were informedthattwoanchor-handlingvesselshadalmostcollided.
RepresentativesofChevron,the“TransoceanRather”shoremanagementandTridentwerenotinformedofthisincidentuntilafterthecapsizing.Nor had the “HighlandValour”entered the inci
dentinherdecklog.Whentheattempttograpplebeganat15:00,the“BourbonDolphin”haddrifted559metresofftheanchorlineandwas2,016metresfromtheanchordeploymentstation.At16:40the drift had increased to 948 metres from theline,andthedistancetotheanchorstationhadincreasedto2,119metres.
9.9 The period up to the capsizing
Thepicture takenfromthe“HighlandValour”at16:31showsthatthe“BourbonDolphin”hadthechain between the starboard towing-pins. Theportinnertowing-pinwasdown,whereastheouterporttowing-pinwasup.
Testimony about the subsequent course ofeventsisafflictedbyuncertaintyasregardsboththefacts,times,sequence,divergentopinionsandprocessingofvisualandotheremotionalimpressions. The survivors of the “Bourbon Dolphin”areclearlyaffectedbythedramatheyhaveundergone.Theotherplayershave,asfarastheycould,attempted to recapitulate their experiences andimpressions. Neither the crew of the “OlympicHercules”northoseinthepilothouseontherig were close enough to get visual impressions of whathappenednext.
The “Highland Valour” proceededwestwardsandhovetoinastandbypositionfromthe“BourbonDolphin”,asshowninFigure9.4.ChiefOfficer Dunlop testified that he registered that the“BourbonDolphin”hadmovedslowlywest.Dun-lopalsotestifiedthatatonepoint,afterthe“High
landValour”hadgonestandby,heheardthetow-master proposing that the “Bourbon Dolphin”connectworkwiretoherchain.
At16:30the“OlympicHercules”askedtoleavethefield,andwasheldbackbythetowmasterwithreferencetothefactthatthe“BourbonDolphin” wassufferingdriftandmightneedassistance.
Communication between the rigand the ves
selswas over an VHF channel.The vessels, too,communicatedamongthemselvesonthischannelduringtheoperations.Nosoundrecoveryofthiscommunication exists, and accounts of what wassaidareinpartconflicting.TheCommissionhasthereforebeenobligedtoconsidertheindividualstatementsaccordingtotheirapparentprobability.
Boththe“HighlandValour”andthe“OlympicHercules” were now aware of the manoeuvringproblems of the “Bourbon Dolphin”. CaptainBergtuntestifiedthatheheardthe“BourbonDolphin”sayingovertheVHFthatthethrusterswere
runningatfullpower.Ithasbeenprovenbytestimonyfromthecrewofthe“HighlandValour”andfromCaptainBergtunthatthesuggestionthattherigpayoutwirewasrefused.Thetowmasterconfirmedthathereceivedsuchanenquiry,buthedid not consider it a good solution, because he wasafraidthatthesituationof the“BourbonDolphin”couldbefurtheraggravated.Thetowmasterexplainedthisintermsofthe“BourbonDolphin”notbeinginthesamesituationasthe“OlympicHercules”,whichhadtheanchorinherwireand
thereforecouldnotpayoutwireherself.Thetow-masterthereforeproposedthatthe“BourbonDolphin”shouldpayoutherwire.
The towmaster stated that neither the OIMnorthebargemasterwasinformedaboutthesituation,despitethefactthathewasafraidthatthemooringofanchorno.3couldbeaffected.
At 16:47 the “Bourbon Dolphin” had drifted1,019metresawayfromthe line.Thisisthebiggestregistereddeviationpriortotheaccident.By16:55thedrifthadbeenreducedto936metres.
Syversentestifiedthatafterthenear-missCaptainOddneRemøyhadcomeontothebridgeandthathetookcommandat16:50.AccordingtoSy versen,RemøyandChiefOfficerBjarteGrimstaddiscussedthesituation.TheChiefEngineer,whonow had overheating in the engine-room,calledthebridgeandaskedforreduceduseofthrusters. Atthispointintimethe“BourbonDolphin”hadaslightand persistent list to port – Able SeamanHafsåsestimateditatlessthanfivedegrees.Observationsfromthe“HighlandValour”,includingphotographs,haveconfirmedthis.
ShortlybeforetheaccidentHafsåsvisitedthebridge. He felt that the atmosphere was ratherstrange.TheChiefOfficerseemedsomewhatanx
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Figure 9.4 Trackplot for the “Bourbon Dolphin” and the “Highland Valour” 12 April
ious, whereas Captain Oddne Remøy appearedmorerelaxed.
AbleSeamanPerJanViketestifiedthathevisitedthebridgebrieflyattwominutesto17.CaptainRemøyandFirstOfficerSyversenwerethensittingintheirseats,whereastheChiefOfficerwasstandingbehindthem.Sandø,whowasoffduty,wassittingatthewindowstationbesidethem.AccordingtoViketherewasanormal,goodatmosphereonthebridgeandhedoesnotrememberanythinginparticularbeingspokenabout.
Listing less than five degrees is noticeable,and on board the “Bourbon Dolphin” they hadtransferredballastfromtheporttank(Tk37WBPS)tothestarboardtank(Tk33WBSB)inanattempttotrimthevessel.
Ontherig’spart,thetowmasterhadproposedthat the “Bourbon Dolphin” connect chain to workwire and run the wire between the towing-pins,soas–accordingtothetowmaster’stestimony–togivethembettermanoeuvrability.Boththe“Highland Valour” and the “Olympic Hercules”
heardthisovertheVHF. The towmastertestified thathe issuednoor
ders,butmadea suggestionthatmightgivethe
“BourbonDolphin”greaterabilitytomanoeuvreherselfawayfrommooringline3.
Captain Bergtun on the “Olympic Hercules”thinks he heard the towmaster suggesting thatthe“BourbonDolphin”shoulddepresstheinnertowing-pinsoastoimprovethemanoeuvringcapabilitiesofthevessel.Noneofthewitnessesonthe “Highland Valour” overheard any such suggestionfromthetowmaster.
GeirToreSyversentestifiedthatthetowmasterproposed that the “Bourbon Dolphin” run downthe inner starboard towing-pin, but that CaptainRemøyandChiefOfficerGrimstadwereatfirstun willingto doso.CaptainBergtuntestifiedthathesubsequently heard from anable seaman on the“OlympicHercules”thatCaptainRemøygotbackontheradioandsaidthattheywouldneverthelesstrytodepressthetowing-pin.AccordingtoSyversen,whowasonthebridge,butnotinvolvedinthediscussion, both the master and the chiefofficer wereworriedbythetowmaster’ssuggestion.Theyalsothoughtthattheanchorthatwaslyingonthe
portsideofthedeckwasintheway. The towmaster has categorically denied hav
inggivenanyordersorconcretesuggestionsto
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Figure 9.5 Trackplot for the “Bourbon Dolphin” from 16:50 until the capsizing
depress any towing-pin. From his station in therig’spilothousehecouldnotseethedeckofthe“Bourbon Dolphin”or any device onboard andthereforehadnoideawhichtowing-pinswereinuse.Hecouldnot,therefore,havegivenanyconcreteinstruction astowhich towing-pinsshouldbeusedornot.
CommunicationontheVHFchannelwasnotrecordedandcannotberetrieved.
Itisnotpossible, therefore, tohaveanydefiniteopinionaboutwhatwassaid.AstheCommissionseesit,thealternativeofdepressingtheinnerstarboardtowing-pinmusthaveappearedasapossibilityforthecrewofthe“BourbonDolphin”,sinceshortlyafterwardsitwasinfactdepressed.
Theweightof thechain layagainstthe inner
starboardtowing-pin,butthevesselwasmanoeu vredtoreducetheloadagainst thepin,sothatit waspossibletodepressit.
This meant that the chain immediately whippedoverontotheouterporttowing-pin.BothGeirToreSyversenandEgilHafsåstestifiedthattheysawthechainsmackoveragainsttheportoutertowing-pinandthattheyheardaloudbang.
Itis2.7metresbetweenthecentreoftheinnerstarboard pins and the centre of the outer portpins, see Figure 5.8. Shortly afterwards the“BourbonDolphin”listeddramatically,accordingtoseveralwitnessesbyasmuchas30degreestoport.Thislastedabout15secondsbeforethevessel righted herself again. The Chief Engineerthereafter warned the bridge that the starboardmainenginehadstopped.Therewasalsoabriefblackout and the “Highland Valour observedblacksmokefromthe“BourbonDolphin”.
Syversen had registered that the tension onthe winch before the towing-pin was depressed was 295 tonnes and that it first fell, but then in
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Figure 9.7 Picture taken at 16:02.
Photo:SeanDickson
Thefollowinginformationhasformed thebasis for an evaluation of the forces and variation
therein:– Daily Report from the vessel with informationaboutdifferentliquidquantities,conferTable9.2.
– Lerwick Port Authority Report on departureShetlandon10April2007,conferSection9.10.2.
– Information from Captain Frank ReiersenregardingindividualcargoesonboardgiventoLondonOffshoreConsultantsandusedintheirstabilityanalyses.
– InformationfromCaptainHugoHansenabouthowhiscrewusedthevarioustanks.Seeminutesofstabilitymeeting,Annex1Section1.10.
– Datafromstabilitymeetingregardingweightsofwire,chainandvariousdeckcargoes.
– Filmtakenfromtherigonamobilephoneatthemomentofthecapsizing(seeFigure9.11).
– Picturestakenofthevesselfromthe“Highland Valour”justbeforethecapsizing,seeFigures9.6and9.7.
– Witnesstestimonyaboutthecourseoftheaccidentandtheloadcondition.
– Lineloads.
TheCommissionhasemployedhydrostaticcalculationsinordertoexplainwhythevesselrolledover. In these calculations the following of the
above-mentioned forcesare included in the vessel’sloadcondition:
– Liquidcargoesonboard(fueloil,freshwater,ballastetc.)– Individualcargoesonboard(wireondrums,
anchorondecketc.)– Tensionfromtheanchorchainwithappurte
nant angle of attack (direction of the chainmeasuredasananglebetweenthisandthevessel’slongitudinalaxis).
The remaining above-mentioned forces will ofcoursehaveaneffect,buttheCommissionconsideredthattheyareofminorsignificanceinexplainingthecourseofevents.
Itmaybeseenfromthepictures,andwasconfirmedinwitnessquestioning,that,priortothecapsizing,thevesselregularlyhadsomeseawaterondeck.Thepicturesshowitrunningoffthedeckandnotbeingshipped;andsoitdoesnotneedtohavehadaneffectinthecapsizingofthevessel. The vessel was affected by wind on her port side.
This will contribute to giving the vessel a small list to
starboard. Calculations using the IMO’s wind and
roll criterion give the vessel a list angle of less than
1º. This will be operationally compensated by use ofthe ballast tanks and has therefore not been used fur-
ther in the calculations; it is more or less negligible.
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Table 9.1 Overview of load conditions
Variation TranscriptinRoll Mean Variable inangle Annex1
reduction chain chain ofattack GM Section1.12,No. Loadcondition tank tension tension ofline (m) Stability Pages
1.1 Departure X - - - 0.89 OK 1-51.2 Lerwick - - - - 1.13 OK -2.1 Condition X X - X 0.95 NotOK 6-10a)2.2 beforetowing-
pindepressed - X - X 1.12 NotOK --3.1 Conditionafter X X - X 0.95 NotOK 11-15b)
towing-pin 16-20c)
depressed3.2 20-24c)
- X X X 1.12 NotOK 21-25c)
a) Angleofattack=25%b) Angleofattack=40%,126tonnemooringlinetensionc) Angleofattack=60%,180tonnemooringlinetension
Forces from thrusters and main propellerscontributetosomeextenttothevessel’slistandtrim.Atthemomentofthecapsizinghalfoftheenginepowerwasoutofactionandthiswasthereforelesscapableofaffectingthevessel’sfloatstatus.
9.10.1.1 Choice of load conditions
The Commission has focussed on the followingloadconditions:
The Commission has emphasised the followinginchoiceofconditions:– DepartureLerwickisofinterestfor:
– demonstrating some of the weights onboard
– (dis)confirming information emergingfromwitnessquestioning
– Conditionbeforethetowing-pinwasdepressedisofinterestfor:– demonstratinguseofballasttankspriorto
thecapsizing– (dis)confirming information emerging
fromwitnessquestioning– Conditionafterthetowing-pinwasdepressed
isofinterestfor:– demonstratingthedirectcauseofthecap
sizing– (dis)confirming information emerging
fromwitnessquestioning
InitsanalysistheCommissionhasbothcorrectedfor free liquid surface by use of the traditional
methodofvirtuallyraisingthevessel’scentreofgravity,dependingontheinertiaofthefreeliquidsurfaces,plusamoreprecisemethodthatmeansthat the liquid’s change in centre of gravity dependingonthelistangleisdirectlyincludedinthe calculations. We have chosen to utilise themoreprecisemethodforcorrectionoffreeliquid
surface in the roll reduction tank and the traditionalmethodfortheothertanks.Thetraditionalmethodgivespoorresultsfortherollreductiontank,withexcessivevaluesforthefreeliquidsurfaceeffect.
From the daily reports the Commissionextracted the following figures that underlie thequantity of bunkers used in the load conditions(seeTable9.2):
9.10.1.2 Tension
The following points of attack for the chain tensionareusedwhenincorporatedintheloadconditions:– Fore-and-aft:
– 3.6mfromaftperpendicular(AP)(topofthesternroller)
Table 9.2 Excerpts from daily reports
FuelOil LubeOil FreshPointintime (m3 ) (m3 ) Water(m3 )
11April2007 464 32.831 147
10April2007 488 32.831 1509April2007 507 33.131 153
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– Vertical: The centre of gravity has beencalculated– 8.17moverthevessel’sbaseline(topofthe onthebasisofthisfigure.
sternroller) – 2.5mtoport(endofthesternroller).This– Transversely: willbethesituationwhenthechainislying
– 0.6 m to starboard when the chain is againsttheouterporttowing-pinandthe
betweenthestarboardtowing-pins.Inthis vesselislisting.Thisismorethan thedis-situationthechainhasanangleofattackto tancefromthecentrelinetotheinneredgeportandmayeasilybeseeninfigure9.6. oftherelevanttowing-pin(1.75m),butis
Figure 9.10 Tank calculations
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regarded as relevant in that the point ofattackwillmovetowardsportthemorethe vessellists.
Inthecalculationstensionisenteredasfollows:
– Theverticalcomponentoftheloadisenteredasastaticloadwithcentreofgravityasstatedabove. The anglebetween the vertical planeandthelineisabout38°.
– Theheelingmomentgivenbythehorizontalcomponent in the transverse direction ismodelledbysettingaforcecoupleonthevessel that intotalyieldsaheelingmoment thatfallsoffwiththecosineoftheheelingangle. Theheelingmoment’sarmiscalculatedonthebasisofthetension’spointofattackverticallytothecentreofthepropulsionpropeller.The
horizontalcomponentinthetransversedirection depends on the anchor line’s angle ofattackvis-à-visthevessel.
Tension used in the calculations is the result ofour own analyses. The calculations were done
withtheprogramsOrcaflexandRiflex.Movementcharacteristicsof the vessel wereobtained fromUlsteinDesign,seeAnnex1Section1.9.
Theanalysesshowthatthereisameanforceof 126 tonnes with a standard deviation of 22
tonnes,seeFigure9.8.Theverticalcomponentofthisforceis100tonnesandthehorizontalcomponent 78 tonnes. The tensions in the simulation varybetween35and240tonnes.AsseeninFigure 9.8, the forces vary between 80 and 180tonnesmostofthetime.Thetensionvariationhasaperiodcorrespondingtothewaves,conferSection9.5.ThisisinconformitywithobservationsmadebyFirstOfficerSyversen,whostatedthathecouldreadtensionoffthewinchas80and180tonnesduringthedeploymentofanchorno.2.
9.10.1.3 Calculation basis
The Commission’s hydrostatic calculations wereperformedwiththeaidoftheprogramShipshape, whichisapprovedbytheNorwegianMaritimeDirectorateforcalculationofstability.
Figure 9.11 Bourbon Dolphin on arrival at Lerwick at 14:35 on 10 April
Photodownloadedfromwww.Shipspotting.com
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In our modelling of the vessel’s geometry,hull,tanks,buoyancyvolumesetc.wehavecompared the results from Shipshape with what wefindinthevessel’sapprovedstabilitybook.
Itisimportantthatthegeometricmodelhas
thecorrectbuoyancyconfiguration.Whencheckingthis,wehavechosentocomparehydrostaticcalculationswiththestabilitybookforarelativelygreatdraught.Thisisdoneinordertocheckthatimportant volumes inter alia in the stern areahavebeenmodelledcorrectly.
Calculation of hydrostatic data for a meandraughtof6.0metresfromthebaselineyieldstheresultsgiveninFigure9.9.
Comparedwith the stability book, the deviationforimportantquantitiessuchasdisplacementis3tonnes(0.06%),forthelongitudinalcentreof
buoyancy(LCB)is0.026m(0.04%ofLPP)andforthe metacentre height (KMt) 0.007 m (0.09 %). Thesedifferencesarewithoutanypracticalsignificanceforthecalculationresults.
All tank volumes have been defined in line withgeometrygivenbyUlsteinVerftinthestabilitybook.
Alistoftranscriptsofcalculatedvolumesetc.isprovidedinFigure9.10.
Volumeandcentreofgravity for thetanks inthemodeldeviateinsignificantlyfromthestability
book.
9.10.2 Load condition 1, on departure fromLerwick
TheCommissionhasrelativelygoodinformationabout the vessel’s load condition on departurefromLerwick.Thisincludesthemainquantityof weights,consistingofwire,anchorsondeckandfueloilandfreshwater.Whatwedonothaveagood idea of is thequantityofwater ballast, includingthecontentsoftherollreductiontanks.
DraughtforthevesselondeparturefromLer wick has been given as 6.2 metres. This is thedraughtthatwasreportedtotheportauthorities. Thevesselhasanavigationaldraughtthatis0.40m greater than the draught measured from the vessel’sbaseline,inthat theskegintheafterendgoes0.40mdeeperthanthebaseline.Draughtatthemarksreferstothebottomoftheskeg.TheCommissionsupposesthatthedraughtstatedisnavigationaldraught,andthatthevesselondeparturefromLerwickthushadameandraughtof5.8
m(fromthebaseline). ThevesselwasphotographedonarrivalatLer wick(seeFigure 9.11).From thispicture itmay
bededucedthatthevesselhadameandraughtofbetween5.8and5.9m.Thiscorrespondstoanavigationaldraughtofbetween6.2and6.3m.Itcanalsobeseenfromthepicturethatthevesselhasaforwardtrimofbetween0.3and0.4m.
TheCommissionfindsthattwoanchorswereexchangedinLerwick(two12-tonneanchorsfortwo18-tonneanchors)andthatthismeantanextradeckcargoforthevesselof12tonnes.Thismakesforanincreaseinthedraughtofabout1213mm.Areportednavigationaldraughtof6.2mondeparturefromLerwickpointsinthedirectionofthevesselnothavingchangedheruseofwaterballastoncallingatLerwickandthevesselthushavingmoreorlessunchangeddraughtandtrimondeparture.
In his testimony, First Officer Syversen has
statedthatmeandraughtondeparturefromLer wickwas6.5m, and that thevesselhada “verysmall” forward trim. The Commission assumesthatthisisthemeandraughtthatreferstothedraught marks and is thus mean navigationaldraught.
AsbothFigure9.11andthereporteddraughtpointinthedirectionofameandraughtofaround5.8m,theCommissionchoosestousethisasaguidelineformodellingoftheloadconditionondeparturefromLerwick.
Inthisconditionfueloilandfreshwaterareallocated in linewith indicationsgivenby CaptainHanseninthestabilitymeeting.
TherewillbeuncertaintyrelatedtothequantityofliquidinsomeofthetankssuchasBilge,Sludge,Sewageetc.Ithasbeenchosentofillalltanksofthistypetoabout30%.
With stated load, stated draught and statements that the vessel was trimmed slightly for ward ondeparture, we find that thevesselmusthavehadwaterballastintheafttanks.AccordingtoinformationgivenbyCaptainHansenatthestabilitymeeting,theCommissionfindsthattheballasttanksT32andT33(seeFigure5.3)wereinusebecauseweightsasstatedanddistributedinthevesselwouldinprinciplehavegivenaforwardtrim.
The Commission has also used ballast tanks T37 and T38 in its calculations, as these tanks wereofteninuse.
9.10.2.1 Load condition 1.1 (Condition with roll
reduction tank) The roll reduction tank T31 could have been inuse on departure from Lerwick. This tank was
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normally filled only with fresh water. If it was filledwithfreshwater,itisassumedthatthiswasstatedindailyreportstothecompany(seeTable9.2)regardingbunkersonboard.CaptainHansenusedonlythisrollreductiontankandnevertank
T30. Hansen has stated that the roll reductiontank was normally in use when the vessel wastransiting,butnotduringanchor-handling.
The load condition for departure from Ler wick with the use of roll reduction tank T31 isshowninAnnex1,Section1.12(pp.1-4).Itappears from this that the condition has a meandraughtof5.80mwithaforwardtrimof0.20mandaGMof0.89m.Thisconditiondoesnotfulfilthestabilityrequirements.
9.10.2.2 Load condition 1.2 (Condition without rollreduction tank)
Alternatively it ispossible that theroll reductiontankswereemptiedandthat the freshwaterwastransferredtotanksT2andT3.Inordertomaintaintrimitisthennecessarytomoveballastback wards in the vessel. Instead of using the ballasttanksT37andT38,tanksT27andT28werefilledcompletely.Thisgivesthevesselaforwardtrimof0.27metresandadraughtof5.80metres.GMis1.13andthestabilityrequirementsaremet.
The Commission regards it as less probablethatthevesselleftLerwickwithoutusingtherollreduction tank. Testimony from Syversen suggeststhatitwasinuse.Itwasalsousualtoutilisethetankintransitconditions.
CaptainHansenhasalsostatedthatthetanks T27andT28werenormallynotinuse,astheyweresmallrelativetotheballasttankslocatedaftinthestern.TheCommissionfindsitimpossibletomodelarealisticconditionthatgivesaGMof0.26minlinewithSyversen’switnesstestimony.EvenwithuseofrollreductiontankT30inadditiontoT31insteadoftheaftballasttanks(T32andT33),itisimpossibletogetanywherenearsuchalowGM.Otherprofessionalmilieuswhohaveconsideredthishave also concluded that it is not possible toachievesuchalowGMforthevessel.TheCommissionthereforefindsthatSyversen’sstatementmustbeduetoerroneousobservation.
9.10.3 Load condition 2, before the towing-pinwas depressed
Inrelationtothevessel’sloadconditionondeparture from Lerwick two days previous, the maindifferencesarethat:
– the vessel had run out both the chains anddeployedananchor,
– somebunkershadbeenusedup,– thevesselacquiredtensionfromthechaindur
ingtheanchor-handlingoperation,and
– thevesselhadchangedballasting. ThepictureinFigure9.7indicatesthatdraughtisstillunder6mandthatthevesselhasaslightafttrim.Inthatallchaininthissituationhasbeenrunout,itisnaturaltosupposethattherigchainlockersT18andT19havebeenfilledwithseawater. This is in line with practice on board, and withoutballastinthesetanksthevessel’sdraught wouldbesmallerthanthepictureindicates.
In that the vesselnowhasavertical force onthesternrollerofabout100tonnes,itisnatural
thatsomeballasthasbeenmovedfromthe tanks T32andT33.100tonneswouldbetheverticalcomponentofthemeanlinetension(126tonnes)inuseofalineangleinrelationtotheverticalplaneof38°.ThisangleistheresultoftheCommission’sowncalculationoftensionloadintheanchorline.
FromquestioningofSyversenitisknownthattheballasttanksT37andT33were inuse,inthattheChiefOfficeratagivenpointtransferredballastfrom the port to the starboard side. We assumethatthetanksT32,T33,T37andT38havebeenin
usetoadjustfortrimandheelduringtheanchor-handlingoperation.Wehavedistributedballastbetweenthesetankssoastoobtainadraughtandtrimforthevesselthatarecompatiblewiththeobservationsfromphotographs.
9.10.3.1 Load condition 2.1
(Condition with roll reduction tank)
Inquestioning,FirstOfficerSyversenstatedthattherollreductiontankwasinuseduringdeploymentofanchorno.2.
Inthecalculationswehaveballastedthevesselwithuseoftanksasshownabovesothatshehasaslittleafttrimaspossible.
Thetensionontheline is126tonnes.This ismeantensiononthechainasfoundintheCommission’sanalyses.Itwillimposeaverticalforceonthevesselof100tonnes.ThehorizontalforceinthetranvsersedirectionvarieswithanangleofattackontheanchorlineasshowninTable9.3.
Figure9.6[ sic]showsthattheangleofattackisperhaps20-25degrees.Thecalculationsshow
that the vessel probably has a listangle of 2-3°even with small angles of attack. This is in line withstatementsfromwitnesses.
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Table 9.3 List angles and horizontal force asfunction of angles of attack, Load condition 2.1
Mooringline’s Horizontal Vessel’sangleofattack transverse listangle(°) force(tonnes) (°)
20 26.3 2.325 32.5 2.930 38.5 3.435 44.1 3.840 49.5 4.345 54.4 4.750 59.0 5.155 63.0 5.560 66.6 5.8
Thecalculationsforarightedship(nolisting) yieldadraughtof5.82m,anafttrimofabout0.31mandaGMof0.95m.Thisconditiondoesnotfulfilallthestabilityrequirements.
Theresults fortheconditionwithanangleofattackof25°areshowninAnnex1,Section1.12(pages6-10).ThecorrectingarmforthisloadconditionisshowninFigure9.12.
9.10.3.2 Load condition 2.2 (Condition without roll
reduction tank)
Forthisloadcondition,too,itisrelevanttoconsidertheconditionwithouttheuseofrollreduction
tankT31.Asfortheconditionabove,thevesselisballastedwithuseoftanksT32,T33,T37andT38.
Calculationsforthevessel’slistangleforvariationoftheanchorline’sangleofattackareshowninTable9.4.
The calculations yield an upright draught of5.80m,anafttrimofabout0.05mandaGMof1.12m.Thisconditiondoesnotfulfilthestabilityrequirements, mostly in consequence of the afttrim.Thenegativemarginis0.08m.
Thecalculationsforloadconditions2.1and2.2donotinthemselvessupportconclusionsonuseoftherollreductiontank.Calculationsforbothcasesareshowntobeprobablebywitnesstestimony.StatementsfromAbleSeamanHafsåstotheeffectthatthevesselhadapersistentlistangleof5°providenoguidanceforthisassessment,asthe
differencesaresmall.
9.10.4 Load condition 3, after the towing-pinwas depressed
Whenthestarboardinnertowing-pinwasdepressedandthechainsmackedoveragainsttheouterportpins,thelistmomentincreaseddramatically.Dependingonthechain’sangleofattack,themomentcouldincreasefurther.Avideocliptakenonamobilephonefromthe“TransoceanRather”justas
thevesselwasrollingover(seeFigure9.13)showsthatthechain’sangleofattackmayhavebeenverygreat--between40and60°.Thiscorrespondswith
Figure 9.12 Correcting and heeling arms for load condition 2.1
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Table 9.4 List angles and horizontal force as afunction of angles of attack, Load condition 2.2
Mooringline’s Horizontal Vessel’sangleofattack transverse listangle(°) force(tonnes) (°)
20 26.3 2.025 32.5 2.430 38.5 2.835 44.1 3.240 49.5 3.645 54.4 4.050 59.0 4.355 63.0 4.660 66.6 4.9
aprobabledirectionforthevesselinordertoreachheranchorstation,seeFigure9.4.
LineshavebeeninsertedintoFigure9.13thatmaymakeiteasiertoseethevessel’sfloatingpostureanddirectionasshecapsizes.
9.10.4.1 Load condition 3.1 (Condition with roll
reduction tank)
Withtheuseofrollreductiontanksandthesamechain tension as before the towing-pin was de
pressed(126tonnes),wehavecalculatedthelistangleasafunctionoftheanchorline’sangleofattack.Table9.5showsthisvariation.
Table 9.5 List angles and horizontal force as afunction of angles of attack, 126 tonnes chain ten-sion, Load condition 3.1
Mooringline’s Horizontal Vessel’sangleofattack transverse listangle
(°) force(tonnes) (°)20 26.3 6.725 32.5 7.330 38.5 7.935 44.1 8.440 49.5 8.945 54.4 9.350 59.0 9.855 63.0 10.160 66.6 10.4
InthissituationthevesselhassomestabilityleftwithapositivereachoftheGZcurveto34°. This is in a situation in which the vessel isstressedwithameantension.Whenthepinisdepressedthevessel,inconsequenceofthedynamicconditions,mayacquirealistangleof15to20°beforesherightsherselfandacquiresapermanentlistangleof7-9°,dependingontheanchor-line’sangleofattack.Forexampleanangleofattackof40°givesapermanentlistforthis
conditionofabout9°.SeeFigure9.14,alsoAnnex 1, Section 1.12 (pages 10-15) for more details.
Figure 9.13 Still from a video taken from the rig with a mobile phone at the moment of the capsizing
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Figure 9.14 Correcting and heeling arms for load condition 3.1 after towing-pin is depressed. 40% angle of
attack, 126 tonnes tension
Accordingtowitnessobser vations,thevesselfirstacquiredapowerfullisttoport,andthereafter quickly more or less righted herself again. The calculations for this load condition cor
respondtotheseobservations.AccordingtothecalculationsshowninFigure9.14,thevesselhasapositiveGZcurveuptoalistangleofabout34°andwillthereforerightherselffromarelativelylargelistangle.
Onlyaftertwoorthreeminutesdidthevesseldevelopapowerfulnewlisttoportthatresultedinthecapsizing.
Wehavealsomadecalculationsforthisconditionforalinetensionof180tonnes.
As previously explained, the tension in thechainvariedmostofthetimefrom80to180tonnes(seeSection9.10.1).Table9.6showshowthelistanglevarieswiththeanchor-line’sangleofattack.
Inthissituationthevesselhasverypoorstability.Withanangleofattackof60°,maximumGZ is as low as 0.035 m. In this situation, notmuchwaveeffectisneededtocapsizethevessel. The GZcurve is shown in Figure 9.15, see also Annex1,Section1.12(pages16-20)formoredetails.
Calculations based on 200 tonnes chain ten
sionandanangleofattackof40°givesacorrespondingGZcurveasshowninFigure9.15.
9.10.4.2 Load condition 3.2 (Condition without roll
reduction tank)
Forloadcondition3.2,wehavefocusedoncalcula
tions for 180 tonnes line tension. This has beendoneinordertoevaluatewhetheritcanbedemonstratedwithahighdegreeofprobabilitythatthe vesselwouldhavecapsizedalsowithouttheuseofrollreductiontankT31.Table9.7showshowlistanglesvarywiththeanchorline’sangleofattack.
Weseefromthecalculationsthatwithanangleofattackof60°,thelistangleis11.8°.TheGZcur-
Table 9.6 List angles and horizontal force as afunction of angles of attack, 180 tonnes chain ten-sion, Load condition 3.1
Mooringline’s Horizontal Vessel’sangleofattack transverse listangle(°) force(tonnes) (°)
20 37.9 8.925 46.8 9.730 55.4 10.535 63.6 11.140 71.2 11.745 78.4 12.350 84.9 12.9
55 90.8 13.460 96.0 13.9
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Figure 9.15 Correcting and heeling arms for load condition 3.1 after towing-pin is depressed, 60% angle of
attack, 180 tonnes tension
ve for this situation is shownin Figure9.16.SeealsoAnnex1,Section1.12(pages21-25).ThisGZcurvemeansthatthevesselshouldhavesufficientstability to tolerate the maximum tension of 180
tonnesevenwithanangleofattackof60°,takingintoaccountthatthevesselislyingwithapermanentlistangleof5-7°withmeanchaintension.
Onthebasisofthecalculationsforloadconditions3.1and3.2,theCommissionfindsthatthecapsizingcanbeexplainedintermsofaprobableloadcondition forthevessel and forces inflictedby the anchor line. The calculations also showthattherollreductiontankmusthavebeeninuseduringthispartoftheanchor-handlingoperation,inconformitywithwitnessobservations.
Withanangleofattackof60°andatensionof180tonnes,thevesselwillacquirealistangleofalmost 15°. The calculation in Annex 1 Section1.12(pp.20-24)showsthatthevessel’sresidualstabilityinthissituationisverypoor.Thedifferencebetweenthecorrectingandheelingarmsisatmaximum12mm.Thesituationisvolatileandcanendinacapsizeatanytime,seeFigure9.14.
9.10.5 Comments on the calculations
Evenifthevesselhadanegativestabilitymargin
inthecapsizingsituationandusedrollreductiontankT31,itshouldbenotedthatinthemodelledloadconditionsthevesselhasaGMthatcanbe
regarded as sufficient toavoid casualty in mostsituations.Itisnotdefectivefulfilmentofthestabilityrequirementsthatistheproximatecauseofthevesselcapsizing.Theproximatecauseisthe
angleofattackthatthemooringlinegraduallyacquiresinrelationtothevesselandthetensioninthisline.
Inarealsituationavesselwouldforabrieftimehavebuoyancyfromthebulwarkintheside,untilwater ran ontothe deckand thisbuoyancyeffectdisappeared.Inthesamewaywatercanbe
Table 9.7 List angles and horizontal force as afunction of angles of attack, 180 tonnes chain ten-sion, Load condition 3.2
Mooringline’s Horizontal Vessel’sangleofattack transverse listangle(°) force(tonnes) (°)
20 37.9 7.325 46.8 8.030 55.4 8.735 63.6 9.340 71.2 9.945 78.4 10.450 84.9 10.9
55 90.8 11.460 96.0 11.8
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Figure 9.16 Correcting and heeling arms for load condition 3.2 after towing-pin is depressed, 60% angle of
attack, 180 tonnes tension
“trapped”ondeckforashortperiodandinasimilarwaycompromisethevessel’sstability.
Itmustingeneralbepointedoutthatevenifastatic calculation for this type of vessel were to
showbothsomeresidualstabilityandalistangleofbetween10and15°,inrealitythevesselwasdynamicallyaffectedbythe waves.The residualstabilityenjoyedbythevesselinsuchasituationmay beinsufficient toavoid capsizingunder theeffectofthewaves.
9.11 Evaluation
Duringdeploymentofthelinesthetensioncameto160tonnes,duetotheweightofthechainand wire.Whenthelastlinewasdeployed,theweatherwasside-ontothevessel.Herthrusterswererunningatfullpower,withfullloadingontheaxlegenerator. Residual bollard pull was thereby reducedto125tonnes.The“BourbonDolphin”thushadnorealisticpossibilityofreachingheranchorstation.AsshowninSection8.3.4,the“BourbonDolphin”hadbeeninvolvedin the recovery anddeployment of several of the anchors withoutproblems.Thereasonwhyshewastooweakforthedeploymentofthelastanchoristhattheoper
ationbeganinamarginalweathersituationwithan unfavourable heading in relation to current, windandwaves.
Mooringlines6and2rundiagonallyoutfromtherigatthesameangleastheprevailingnortheasterly current (the Gulf Stream) in the area,conferFigure6.3.Thechallengesofforcingalat
eral current are thus direct comparable for thetwomooringlines.Experiencegainedindeploymentofanchorno.6willthereforeberelevanttodeploymentofanchorno.2.
With her continuous bollard pull of 250tonnes, the “OlympicHercules” was the biggestandmostpowerfuloftheanchor-handlingvessels. The“VidarViking” isalsobiggerand morepowerfulthanthe“BourbonDolphin”andthe“Highland Valour”. It is clear that during the deploymentoftheanchorthe“OlympicHercules”developed a considerable drift that could not becorrectedbytheordinaryuseoflateralthrustersandthevessel’spropulsionengines.
Inthelightofthetowmaster’stestimony,noappreciableweightwaslaidonthefactthatthe“Olympic Hercules” drifted from the line. Thetowmaster maintained that deviations were normalandthatitwasuptothemasterandcrewoftheindividualvesseltoevaluatethesituation,andifnecessarysuspendthejob.
The Commission would remark that in thiscasetheydidnotappeartohavereflectedthatthe
problemsencounteredbythe“OlympicHercules”mightresultfromthecurrentbeingstrongerthanexpected.Thishadatransfervaluewhendeploy
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mentofanchorno.2wastobeperformedunderthesamecurrentconditions.
The“OlympicHercules”wasprimaryvesselonanchorno.6.The“HighlandValour”wastoassist,butwasdelayedbyaminorrepair.The“VidarVi
king”wasthereforeinstructedtoassistonanchorno. 6. Despite the fact that thischange in vesselcompositionmeantthatthetwomostpowerfulvesselsweretoworktogetheronanchorno.6,whereasthetwosmallervesselsbecamepartnersonanchorno.2,ithasnotprovedpossiblefortheCommissiontofindthatontheoperator’spartthisledtoachangedassessmentofriskexposure,weatherandcurrentconditions,oraloweringofthethresholdforsuspendingtheoperation.
AstheCommissionperceivesit,thoseresponsibleontheriglaiddecisiveemphasisonthefinal
result, namely that anchor no. 6 should be deployedinthecorrectposition.Itappearstohavebeenwithoutsignificancethatalongthewaytheyexperienced drifting, unexpected current forcesanddemandingandriskyworkonthepartoftheinvolvedvessels’crews.
The towmaster and others in the rig’s pilothousehadcurrentinformationonthevessels’location.Inadditiontodirectobservationwithbinoculars,therewerecomputermonitorsonwhichthevesselmovementswerecontinuouslyplotted.
Therewasalsoacompetentnavigatorpresent. The operator and the rig have made it clearand explicit that they have no responsibility formaritimemattersonthevessels,andthatitwillbeuptothemasteronboardtosuspendanongoingoperation thathedoesnot regardas defensible. TheCommissionhasnodoubtthatademandtosuspendtheoperationwouldhavebeenrespectedimmediately,ifthe“BourbonDolphin”hadmadesuchademand.
Tothedegreethat tandemoperationsduringdeploymentofanchorsisdealtwithintheRMP,thisconcernsloweringofanchorsafterchainhasbeenrunoutandtheanchoroverboardedatthestern roller. The towmaster’s written procedureforthelastanchordoesnotinvolveanyextendeduseoftwovesselsatanearlierstage.
Undertheupdatedprocedureof10April,the“Vidar Viking” was to assist the “Bourbon Dolphin”.Italsoappearedthatgrapplingwastobedone in connection with the running out of anchorstotaketheweightoftheanchorchain,thatis,notbeforethevesselhadcomeonstation.The
distancetothegrapplingvesselwasstatedtobe300metres.
Inthedeploymentofanchorno.2theupdatedprocedure was departed from on five majorpoints:– grappling was done with a differentpurpose
than described in the procedure, namely to
assistavesselthatwasdriftinginanuncontrolledmanner– the“BourbonDolphin”wasabout2,000metres
fromheranchorstation– whengrapplingstartedthe“BourbonDolphin”
was about 430 metres from the “Highland Valour”
– themooringlinewasnotcomplete– assistancewasgivenbythe“HighlandValour”.
Thegrapplingmeasureinitiatedbythe“Highland Valour” seemed casual and not very expedient.
Neitherthe“BourbonDolphin”northe“Highland Valour” indicated having undertaken a specialevaluation of the increased risk exposure thatsuchameasureinvolvedforbothvessels.Asfortherig,itrestricteditsresponsibilitytograntingthe request for assistance without looking moreclosely at possible consequences – both for therig’s mooring and for materiel and crew on thetwovessels involved.Nor isit clearwhether thetowmaster thought that the “Highland Valour”andthe“BourbonDolphin”,hadtheysucceeded,
shouldpullthechaintogether,andifsoonwhatpattern,whethertheyshouldgetawayfromline3or whether the vessels should stay on stand-byandifsoforhowlongandinexpectationofwhat.Nor,forthatmatter,isasidewaysoperationoftwo vesselsenshrinedintheRMP.
There is no direct connection between thegrapplingattemptandtheaccident.Theincidentsshow,however,thatevenatthatpointtheywereinasituationthatwasdifficulttocontrolandthathadnotprovensusceptibletocorrectionbyverbalinstructionsorthemeasuresattempted.
Neitherthesubstantialdrift,theunsuccessfulgrappling attempt or the near-miss with the“HighlandValour”hadanydirectsignificanceforthe negative development of the “Bourbon Dolphin” listing and later capsizing. Nevertheless,these incidents help to draw a picture ofan anchor-handlingoperationthatinitsfinalphasewasoutofcontrol.
The grappling attempt lasted from 15:00 to16:40.Itspurposewastobringthe“BourbonDolphin”back totherun-out line,butinsteadledto
thedriftincreasingbyabout400metresandthedistancetothestationforanchorno.2growingbyabout100metres.
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Evenifthecrewofthe“HighlandValour”hadbeenwarnedto“expecttheunexpected”,itisdifficultfortheCommissiontoconcludeotherwisethan that theyhad gonebeyond the unexpectedaswell.Giventhat therepresentativesof the rig
andtheoperatorhadwitnessedsuchoccurrences,itisdifficultfortheCommissiontoseewhythe totality of the operation was not reassessedandperhapssuspendedbythosewiththeultimateresponsibility. This must apply even if the paramountcommanderonthevesselhadnotdemandedthattheoperationbesuspended.
Through its investigations the Commissionhasdiscoveredthatthekeepingoflogsonboardontherigwasincomplete.Eveniftherearenoclearrulesforlog-keeping,theobjectistosecurecontinuousregistrationofimportantinformation
andmakethisavailabletoeveryonewhoneedsit. TheOIMdidnothaveimmediateresponsibili
ty for the maritime operations during the rigmove.Thiswasvestedinthetowmaster.Asthepersonultimatelyresponsiblefortherig,however,hehadboththerightandthedutytokeephimselfinformedaboutprogressandimplementation,interaliainordertoassurehimselfthattherig wasproperlymoored.
The “Transocean Rather” had chosen an arrangementwherebythefunctionsofChevronMa
rine Representative and Transocean Towmaster weremergedandvested inoneperson,whowasemployedbyneitherChevronnorTransocean.Inhiscapacityofmarinerep,thetowmasterreportedtoChevron’sshore-basedmanagement.ReportingbetweenthetowmasterandtheOIMwasnotformalisedoverand aboveregularmorningmeetings.During the day-to-day tasks there was informalcontactbetweenOIM and towmaster.From whatthe Commission has been given to understand,their respective offices were close,and the fromtimetotimetheOIMvisitedthepilothouse.
IntheopinionoftheCommissionitmeritscriticismthatthetowmasterdidnotkeeptheOIMcontinuouslybriefedaboutthesituationthatwasdeveloping.ItisalsoincompatiblewiththeOIM’sdutiesthattherewerenofixedroutinesfornon-conformance reporting on the rig. As early as 14:30 the“BourbonDolphin”hadwarnedtherigofhermanoeuvringproblemsinrelationtotherun-outline. Theproblemswerenotcorrected.Thiswasnotamatterofasituationthatarosesuddenlyandunexpectedly, but a situation that had been warned
aboutandwasgraduallydeteriorating. The “BourbonDolphin” followed the instruc
tionsfromthetowmastertoproceedwestwards,
awayfromanchorline3.Itmayappearthatneitherthe towmasternor themasterwasawareofthedangerinherentinthechainacquiringanangleofattackthatgraduallyincreasedasthevesselchangedherheadingtothewest.Thechainwas
directlyaffectedbycurrent,at thesametimeasthe vessel’s movements in the sea affected thedragfromthechain.
Thepointofattackforthechainonthesternrollerwas dramatically changed when the innerstarboardtowingpinnolongersecuredthechainonthestarboardside.Theloadagainsttheouterportpin,incombinationwiththeangleofattackofthemooringlineinrelationtothevessel,createdthesituationthatendedinthelossofthevessel. Thevessel’scurrentloadcondition, theinfluenceofcurrentandwavesandreducedmanoeuvrabili
tyafterthestarboardmainenginestopped,madeitdifficultforthevesseltoextractherselffromthesituation.
TheCommissionfinds that thedepressionoftheinnerstarboardtowing-pinwasdiscussedonthe“BourbonDolphin”inthecriticalperiodrightbeforethecapsize.TheCommissionwould,however,remarkthatneithertheofficersofthe“BourbonDolphin”northetowmastercouldhavebeenawareofthestabilitychallengesinvolvedintheuseoftheoutertowing-pinsinthegivensituation.
TheemergencyreleasewasnotactivateduntilSyversenleft the bridge when the vesselheeledforthesecondtime. Itappears tohavebeenthegeneralperceptiononboardthattheemergencyreleasefunctionofthewinchactedasaso-called“quickrelease”thatcausedspontaneousandfullunspoolingofwireorchainonthewinchassoonas activated. In the Commission’s opinion, thismisunderstanding may help to explain why thisemergencymeasurewasnottakenearlier.
As demonstrated, constant tension on the winch cannot have been as high as 330 tonnes. TheCommissionwouldnot,however,ruleoutthepossibility that tensionatsomepointin timeimmediately before the capsize can have shownsuchabigloadonthewinch.Innocircumstanceshadsuchahightensionbeennecessarytocapsizethevessel.AsshowninSection9.10,thevesselcancapsizewithalinetensionof200and180tonnes,withanangleofattackof40°and60°respectively.
Nocost estimate for the operation has beensubmitted to the Commission. The five vessels
werehiredonfixeddailyratesofaconsiderablesize.Therewerenotime-framesintheseagreements.
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Eveniftheoperatorhasemphasisedthatthesafetyoftheoperationisalwaysconsideredmoreimportantthanrapidimplementation,thereisalsoreasontobelievethattheoverallcostoftheoperationwasalsoundercontinuousreview.
In the Commission’s opinion, the possibilitycannot be ignored that a conscious or unconsciouswishtogetfinishedonthepartofthosein volved may have led to an inadequate focus onsafetyintheconcludingphase.
The RMP calculated the operation as takingfivedaysandeighthours.Fromthestart-upon26March, when the “Olympic Hercules” and the“Bourbon Dolphin” were hired, as the first two vessels,until12April,wasmorethan18days.Theoperation was thus considerablydelayed. Ithadbeen hampered by the weather and there had
beenotherdelays,interaliaequipmenthadtoberepaired and replaced. Several people indicatedthattherehadbeenalotofwaitingandthattheoperation had been fragmented and sometimesnotverystructured.
On12Apriltherighadbeenmannedtostartdrilling.
Itisparticularlydifficulttoretainafixedfocusonthesafetybarriersevenattheendofanoperation.Experienceshowsthatforonereasonoran
otherhumanattentionwillalwaysbedistracted.Ifanoperationisperceivedasroutine,ifeverythinghas gone well previously, if the people involvedareforvariousreasonsimpatientandwanttofinishup,itiscrucialnottoeaseoffonthesafetyrequirements.Insuchasituationitisessentialthatnoone is pressured orallows themselves tobepressured.
In this context the Commission would alsopointoutthatoneoftheanchor-handlingvessels,the“VidarViking”,hadbeengivenpermissiontoleavethefieldbeforetheoperationhadbeencom
pleted.Thatwasunfortunate,forreasonsofsafetyandemergencyresponse.
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Chapter 10The rescue operation
10.1 Introduction
TheCommissionwillprovideonlyadescriptionoftherescueoperation.Itliesoutsideitstermsofreferencetoevaluatehowtheoperationwascarriedout.TheH&SE(Health&SafetyExecutive)
hasstatedthattheyareundertakingainvestigationoftherescueoperationinScotland.Themainfocusistolookatpotentialforimprovement,notto make anyone responsible for any errors andfaults. The investigation is still in progress andhadnotbeencompletedwhenthispresentreport wassubmitted.
The following account will operate with precise times. The information has been obtainedfromvariouslogs.Synchronisedclockswerenotemployed,norcanwebesurethatallinformation
was logged immediately. Even if there may besmalldiscrepancieswithregardtoaccuracy,theprecisionisregardedasbeingofsuchaqualitythatwecanrefertothetimesasstatedinthelogs. There exist several logs and the time stated forthe same communication may vary somewhatfromlogtolog.Itisamatterofverysmallvariations.
The information in this chapter is obtainedfromthefollowingdocuments:1. Towmaster’slog,keptontherig,seeAnnex1
Section5.1.2. Ballastcontrolroomlog,keptontherig,see
Annex1Section5.4.3. Transocean Emergency response log, see
Annex1Section5.3.4. Chronologicallistofeventsatsite,seeAnnex1
Section5.5.5. JointstatementbyChevron/Trident/Trans
ocean.6. MaritimeandCoastguardAgency7. MainRescueCentreSola(HRS)8. Operational log, Sunnmøre Police District
(LRS)9. Trident’snavigationlog,seeAnnex1Section5.2.
Thesedocumentswillalsobereferred tolaterinthechapter,byquotingsolelythenumberofthelogordocument.Forexample,theemergencyresponselogwillbereferredtoas“(3)”.
10.2 Raising the alarm – establishment
of rescue leadership
OIM Patrick O’Malley was in the pilot house whenthe“BourbonDolphin”capsized.Heimmediatelyraisedthealarm,andtookcommandoftherescue work. The “Highland Valour” and the“OlympicHercules”wereatoncerequestedtoassist,aswasthestandbyvessel“VikingVictory”. Accordingto therig’s towmasterlog(1),thecapsizingoccurredat17:10,whileinTrident’snavigationlogitisgivenas17:08(9).
Transocean’s shore-based management andtheBritishcoastguardwerenotifiedat17:16(4). Aminuteafterthat, theOIMactivatedthe emergencyalarmforthecrewontherig.
In his testimony to the Commission, Chevron’sPeterLee,MOE(ManagerforOperationalExcellence) stated that hewas alerted at 17:15.Necessary personnel were called into Transocean’sofficeinAberdeenwhereanemergencyresponseroomwasestablished.Transoceanwasassigned the main responsibility for the rescue work,withtheOIMason-sceneleader.Chevronassistedwithallthesupportnecessary.
Chevron undertook responsibility for logisticsandpersonnelquestions,dealingwithsurvi vors, next of kin and evacuated personnel fromtherig.Chevronestablisheditsownemergencymanagementteam,andinadditionacrisisteam. Thelatterwasto relievetheemergencymanagement team with regard to external communication so that the emergency management teamcouldconcentrateasmuchaspossibleontheoperationitself.Chevronhadnolocalrepresentative
inShetland,andthefirstprioritywastoestablishlocalrepresentation.Theygotholdofaretiredpoliceofficerwithexperienceofboththeoilandgas
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industryandofcrisissituations.ChevronwasalsoincontactwithBourbonOffshore,whichwantedassistance with accommodation and any otherhelptheycouldgivethesurvivors.
10.3 The survivors
FirstOfficerGeirToreSyversenhad succeededingettingoffthebridgebyclimbingoutthroughadooronthestarboardside.Atthispointintimethelistwassogreatthathehadproblemsgettingthedooropen.InadditiontoSyversen,ChiefOfficerBjarteGrimstadandAbleSeamanTorKarlSandø attempted to get through this door. ThelastobservationsthatSyversenmadeofthesituationonthebridgewasthatCaptainOddneRemøy,
hissonDavidRemøyandSandøwereslippingorfallingdowntotheportside.SyversenhasalsotestifiedthathesawKjetilRuneVågeintheprocessofputtingonasurvivalsuit.Aftergettingout,Syversenclimbedupontotherailingonthestarboardside.Itwasaboutatthatmomentthevesselrolledover.
Syversen was pulled under water when the vessel rolled over. Whenhecameup to thesurface,hewasabouthalfametrefromthevessel.Hehadnothadtimetodonanysurvivalgear.The
vessel drifted away from Syversen. He spotted AbleSeamanPer JanVike, whowaslyingin the waterwearingalife-jacket.Syversenswamoverto Vike,andclungontohim.Afterashortwhiletheymanagedtoclimbaboardafloatthatdriftedto wardsthem.Thefloat,whichwaspartlyfullofwater,wastheonlyoneofthevessel’srescuefloatsthathadreleased.
Able SeamanPer Jan Vike was sitting in the TV room (the smokers’ mess) when he noticed thevessellistingtoport.Thelistwassopowerfulthathesawtheseajustunderthescuttlewhenhelookedout.Afterdonningalife-jackethetriedtoclimbafterthevesselasshecapsized.Hejumpedintotheseaandmanagedtopositionhimselfaftertheabove-mentionedfloat.
Able Seaman Øystein Sjursen was sitting inthelobbyonmaindeckwhenhenoticedthevessellistingtoport.Hewenttothecontrolroom, where Chief Engineer Frank Nygård, engineerRonnyEmblemandelectricianSørenKroerwere. There,onascreen,hecouldseethewinchesandthechainsthatranthroughthetowing-pinsand
outintothesea.Hesawalotofseawatercomingondeck.Hewasworried,andreturnedtothelobby.HerehemettraineesKimHenrikBrandaland
ThomasArnesenandranwiththemuptoADeck, wherehemetAbleSeamanEgilAtleHafsås.Hafsås opened the locker containing life-jackets.Sjursenunderstoodthatthiswasgoingtogobadly. Heclimbed over the railing and uponto the
vessel’sside.Atthispointheheardthe“abandonship”alarm.Whenheunderstoodthatthevessel wasnotgoingtorightherselfagain,hepanickedandjumpedintothesea.
Sjursenfirsttriedtoswimtowardsacontainerthathadbeenondeck,butsawthattherewasarescue float that was closer to him. When hereachedthefloathesawthatGeirToreSyversenandPerJanVikehadalreadyclimbedintoit.
Just after the inner starboard towing-pin wasdepressed,thevessellistedpowerfully,about30°on Hafsås’ estimate. The vessel righted herself
again,butHafsåsdecidedtoputonasurvivalsuit.OnADeckhemanagedtoopenthelockercontaininglife-jackets.HerehemetthetraineesArnesen and Brandal and gave them their jackets. Whenhewenttofetchthesurvivalsuitthevesselhadablack-out,butthepowersoonreturned.The vessel listed and he went along the side of theshipandfellintothesea.Ashewaslyingintheseahesawarescuefloat,butitwastoofarawayforhimtoreach.Healsosawacontainerthathadcomeloosefromthedeck.Thecontainerdrifted
towardshimandhemanagedtoclingontoit,together with Brandal and Arnesen. They weredriftingsteadilyfurtherfromthe“BourbonDolphin”.
The cook Ånje Nilsen was sitting with AbleSeamanPerJanVikeandwatchingTVwhenthe vessel listed strongly to port. They went to theexitandgotholdoflife-jackets.Nilsenwasstandingontheportsideof theshipandafterawhilethevessellistedsosteeplythathefellintothesea.Hebegantoswimawayfromthevesselassoonashewasinthewater.Hesawtwoofthecrewcominguptoafloat,whilethreeothersweremanagingtoholdontotowhathethoughtwasaplasticbarrel.Hehimselflayinthewateruntilhewaspickedupbyarescuecraft(25minuteslater,byhisownestimate).
The “Highland Valour”, which was the shipclosesttothe“BourbonDolphin”,beganimmediatelytoproceedinthedirectionofthecasualty.SkipperGordonKeithWilliamshadobservedthecapsizingfromthebridgeandhadtriggeredthemain alarm.The “Highland Valour” took station
east of the “Bourbon Dolphin”. The crew couldseesurvivors,inadditiontoflotsamfromthecasualty.Itwasalsotestified thataMOBboatwas
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launchedat17:30.TheMOBboatwenttothecontainer to which Egil Atle Hafsås, Kim HenrikBrandalandThomasArnesenwereclinging.Thethreeofthemweretakenaboardthe“Highland Valour”, where they stayed until about 21:00,
whentheywereflowntoTingwall. At17:17(5)the“VikingVictory”deployedherfirstFastRescueBoat(FRV),andthreeminuteslater her second rescue boat was launched. At17:26(4)therigwasinformedthatoneoftheserescueboatshadpickedupasurvivorfromthesea.Thiswasthecook,ÅnjeNilsen.Hewastheonly one of the seven survivors who had notclimbedontoafloatorfoundsomethingtoclingonto. Nilsen was frozen and was given freshclothes,andtheytriedtokeephimwarm.Afterbeinginthevessel’ssickbay,at20:34(4)hewas
fetchedbythehelicopterandflowntoahospitalinShetlandwherehewasexaminedbyadoctor.He wasinthehospitalfor2-3hours.
AfterÅnjeNilsenwas takenonboardthe“Viking Victory”, Syversen, Sjursen and Vikewerepickedupbythatvessels’rescueboatandthentakenonboardthemothership.TheyremainedonboardthisvesseluntiltheywereflowntoTing walltogetherwithÅnjeNilsen.
Thesevensur vivorswerereunitedatthehospitalinTingwall.Afterbeingexaminedatthehos
pitaltheyweregivenroomsatLerwickHotel,andshortlyafterwardsquestionedbytheScottishpolice.
10.4 The search for the missing
The rescue boat from the “Highland Valour”pickedupthreeofthesurvivors.Therescueboatsoftheothervesselswere,however,moresuitableunder the prevailing weather conditions. Thecrewthereforereturnedtothe“HighlandValour”again. The vessel continued to search for themissing.
Captain Grim Are Bergtun of the “OlympicHercules”statedthathisvesselwascalledupbytherigat17:10.Theycameuptothecasualtyafterabout20minutesandimmediatelylaunchedtheirMOBboattosearchforthosestillmissing.Atthatpointthesevensurvivorshadalreadybeenpickedupbythe“VikingVictory”andthe“HighlandValour”. Various minor objects from the casualty were found, among other things life-jackets and
lifebuoys, but no persons. They continued thesearchthroughtheevening,thewholenightandthenextday.
At17:43(4)itwasstatedthattwopersonshadnowbeentakenaboardthe“VikingVictory”.Oneofthem,BjarteGrimstad,wasdead.Thesurvivor was, as previously described, Ånje Nilsen. ÅnjeNilsen testified that after he had been taken
aboard the rescue boat of the “Viking Victory”,BjarteGrimstadwasfound.NilsenwasquitecertainthatGrimstadwasalreadydeadwhenhewasbrought aboard the “VikingVictory”.AccordingtoNilsen,Grimstadwasnotwearingalife-jacketorsurvivalsuit,butonlycamouflagetrousersandajumper.
Intheintroductoryphaseoftherescueoperationthereprevaileduncertaintywithregardtothenumberofpersonswhohadbeenonboardthe“BourbonDolphin”.AccordingtotheTransoceanemergencyresponselog(3),notuntil18:39wasit
confirmedviainformationfromthecompanythatthecorrectfigurewas15.Beforethis,thevariouslogswereoperatingwith12,14,15and16persons.Inthefirsthecticandconfusingpartoftheoperation, there were also divergent messagesaboutthenumberofsurvivorsandmissing.Intherig’s towmaster log (1), for example, it was enteredat17:34thatthe“HighlandValour”reportedeightsurvivors,whereasthecorrectnumberwasseven.Itwasmadeclearthatthiswasanunconfirmedmessage.Therewasalsoerroneouslogin
formationat17:57(4)totheeffectthatfivesurvi vorshadbeentakenonboardthe“Viking Victory”,whereasthecorrectfigurewasfour.Thesefour were Ånje Nilsen, Geir Tore Syversen, Per JanVikeandØysteinSjursen.
At17:30(4)theriggotconfirmation thattwohelicopterswouldbeassignedtotherescueoperationandwereexpectedtoarriveatthelocationat18:10.Thehelicopterswereonthespotat18:22(4)and18:26(4),andimmediatelybegansearching forpeople inthesea.Thefirsthelicopterreportedat18:34(4)thattheyhadpickeduponepersonandwerereadytolandontherig.At18:40(4) the otherhelicopter reported that they, too,hadpickedupaperson.At18:44(4)bothpersons werebroughtaboardontherig.Inbothcasesthelogusedtheterm“casualty”.AccordingtoChevron, this term is used until the facts are established,incasethecommunicationisbeingmonitoredbyunauthorisedpersons.At18:56(4)both weredeclareddead.ThedeceasedwereCaptainOddneRemøyandFirstOfficerKjetilRuneVåge. The log information does not say who was on
whichhelicopter.LaterintheeveningtheairbornesearchwasfurtherintensifiedwiththeuseofNimrodmari
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timesurveillanceaircraft.Thefirstplanewasdeployedintheoperationat19:00(4),andwaslaterrelieved by another aircraft of the same type. Theseplanescouldbeused to localise themissing.
CaptainHalvorMagnusEnoksenofthe“Vidar Viking”testifiedthathewasnotifiedofthecapsizingbymaydayat18:15.The“VidarViking”hadleftthefieldat13:25.Theywerebackatthelocation and began to search for missing at 22:00. Withthe“VidarViking”inplace,atthispointfive vesselswereparticipatingintherescueoperation. The search for themissing continued thewholenight.Nextmorningat08:12(4),the“VidarViking”reportedthattheyhadfoundtheMOBboatfrom the “Bourbon Dolphin” 15 nautical milesfrom where the capsizing happened. There was
otherwise agoodsupply ofvesselsvolunteeringtoparticipate in the operation. For example the vessel“IceFlower”offeredtoassistintherescueoperationat20:16(4);shewasnotused,butsatonstandbyincaseshewasneededlater.
At 19:52 (4) the coastguard was informed ofthenamesofthepersonswhohadbeensaved.Inthiscontextitmightbementionedthatnotuntil00:21(UKtime23:21)wastheoperationscentreinSunnmøreabletoconfirmthenamesofthesur vivors.Thiswas information thatcameviaBour
bonOffshoreNorwayAS’officeatFosnavåg,andnotfromBritishrescueauthorities. At 20:56 (4) one of the helicopters was re
leasedfromtherescueassignmentbythecoast-guard,inordertotransportsurvivorstoTingwall.ShortlyaftertheotherwassenttoShetlandtorefuel and bringnavy divers back to the accidentsite.Afterthattimethehelicopterwasnotusedtosearchforthemissing.Throughthenight,thehelicopter capacity was used to evacuate the platformcrew.AirbornesearchforthemissingcontinuedthroughthenightwiththeNimrodaircraft.
At21:25(4)yetanotherstandby-vesselofferedits assistance. This was the vessel “GrampianFrontier” which had been on the BP Foinavenfield.Thecoastguardhadearlieraskedvesselsforequipmentfordivingoperations,andthe“Grampian Frontier” had a compression chamber fordivers.Thevesselarrivedat23:28(4).
At 22:00 (4) word went out that the searchshould continue through the night. The “HighlandValour”wasdesignatedtocommandtheparticipatingvesselsandalsomonitoredtheposition
ofthe“BourbonDolphin”.At22:32(4)the“HighlandValour”reportedthatthecasualtywaslyingdeeper in the water. In subsequent reports
through the night, no changes in the casualty’sbuoyancywerereported.
At 22:56 (4) the helicopter with three diverslandedontherig.Thediversweretooperatefromthe “Grampian Frontier”. At00:37(4) the divers
werereadyto flyouttothe “GrampianFrontier”. At01:57(3)oneof thediverswas transferred tothe “Subsea Viking”; he was to go through picturestakenbyaROVminisubwithaviewtomakingsurethatitwouldbesafetodiveunderneaththe casualty. At the same time, the other twodiversundertookacloserinspectionofthehullofthe “Bourbon Dolphin”. Thereafter these two werealsotakenonboardthe“SubseaViking” inordertoevaluatethepicturestakenofthebottomofthe“BourbonDolphin”.ItwasalsotheintentionthattheROVshouldaccompanythedivers
andobservetheirwork. Throughthenight furtherobservationswere
undertaken with the ROV. The weather conditionsweredifficult,andat05:48(4)itwasdecidedto suspend further investigations with the ROVuntilthecurrenthadslackened.Theweatherconditionsmeantthatthediversdidnotfinditadvisable to enter the water. At 09:56 (6) pessimism with regard to thechancesofbeingable todive wasexpressed.Inthecoastguard’slogthetimeisgivenas08:56GMT.
InthemorninganewROVinvestigationwasmade.At12:53(11:53GMT)itwasenteredinthecoastguardlog(6)thatpicturestakenbytheROVshowedsomethingthatwasthoughtmightbeoneof the missing, on the bridge. Even though theconditionsweredifficult, itwasdecidedthat thedivers should undertake an investigation of thecasualty.Thefirstdiverwasinthewaterat13:41(4),andintimeallthreeofthediversparticipatedintheoperation.InthelightofthefilmingdonebytheROV,thediversconcentratedonthebridgeofthe“BourbonDolphin”,soasifpossibletofindthemissing.Thediverswerenotinthevessel,butforsafetyreasonswereinstructedtomaketheirobservationsfromoutside.Thedivingcontinuedupto14:50(4).Thediversthenreturnedtothe“Grampian Frontier” and stated that it was notpossibletomakefurtherdivesbecauseofexcessivecurrentandwaves.At15:26(4)thediversreportedthattheyhadseennosignsofanyofthemissing.Theylaterstatedthattheywere95%certainthatnoneofthemissingwereonthebridge.
At thesametimeas thediversarrived at the
site,apartialevacuationofthedrillrigwasunder way,sinceacollisionbetweenthecasualtyandtherigand/ormooringsystemwasfeared.Afterthe
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divershadbeentakenouttothe“GrampianFrontier”, the precautionary downman of the rig began. It was decided to evacuate personnel who werenotvitaltothesafetyoftherig.Thiscovered72ofacrewof99.Evacuationbeganat00:21(4)
and was, according to Peter Lee, completed at06:00nextmorning.Inthecourseofthenight,at02:20accordingtotheTransoceanemergencyresponselog(3),therewasalsocontactwithtechnicalmanagerBjørnBergsnesofBourbonOffshoreinordertodiscussapossiblereleaseofthe“BourbonDolphin”fromthechain.
At 15:45 (4) the rig was informed by coast-guardthattheoperationwaschangingitsnaturefromarescueactiontoasalvageoperation.The vesselsparticipating intheoperationshould neverthelesscontinuesearchingformissing.
DuringtheCommission’shearingsitwasstatedbyTransocean’sRigManagerAdrianBrownthatascenariofeaturingthecapsizeofavesselinanchor-handlingwasnotsomethingtheyhadeverdrilled for. According to him, this was aneventthatwasimpossibletoforesee.Inthelightofthenear-missat16:25,hewasaskedwhetheracollisionbetweentwovessels,andapossiblecasualty, was something they drilled for; he answered inthenegative.Transocean’sprocedureshadnorequirementsforrescuedrillswithaviewtosuch
situations.Intheprocedurestherewasarequirementthattheydrillformanoverboardsituationsandcollisionsbetweenrigandvessel.ThetestimonyfromBrownisincludedinspecialAnnex2Part8.
PeterLeetoldtheCommissionthat,theweekaftertheaccident,Chevronundertookanevaluationoftherescueoperation.Everyonewhohadarole in the emergency response participated.Someexperiencesweregainedanditwasrecognisedthatcertainthingscouldhavebeendonedifferently,butbyandlargetheemergencyresponsehadbeenaseffectiveasitcouldbe,giventhetragic circumstances. One of the things they hadlearnedwasthatitwasimportanttohavealocalrepresentativeinShetlandinordertosupportforsurvivorsaftertheycameashore.Inthiscaseithad worked well, because they were luckyenoughtofindasuitableperson(aretiredpoliceofficer). Chevron has now formalised this elementoffutureincidents.
Itwasalsofoundthatjurisdictionhadcreated variousproblems.Therewasa lackofclarityre
garding the responsibility of the various BritishandNorwegianauthorities.Theyhadtodealwithtwo different police districts in connection with
thedestinationsofthedeceasedandthe72evacuees. Uncertainty also prevailed with regard toNorwegian jurisdiction over the deceased. Thishadresultedincontradictoryinstructions.ChevronandTransoceanhaveheldameetingwiththe
policeauthoritiesinordertogetthistofunctionmoreflexiblyinfuture.
10.5 The Main Rescue Centre at Sola/the local police in Norway
The Main Rescue Centre at Sola, outside Sta vanger, (NorwegianabbreviationHRS) wasnotified of the capsizing at 18:24 (7) by the MRCC(MaritimeRescueCo-ordinationCentre)inAberdeen. About fifteen minutes had then elapsed
since the capsizing, which took place at about18:08Norwegiantime.Accordingtothelogthemessagewasthatthe“BourbonDolphin”hadcapsized north-west of Shetland during an anchor-handling operation.The situationwasdescribedasunknown,withoutthisbeingamplifiedfurther. TheHRSwasrequestedtofindtheownerandobtaininformationabouthowmanywereonboard.MRCCAberdeenstatedthattherewerenormally12persons,butthattheylackedpreciseinformation.
ViavariouselectronicsearchestheHRSfoundtheowner,BourbonOffshoreAS.ContactwasestablishedwiththeOperationManager,BjørnIdarRemøy.Hewouldsethimselfupatthecompany’sofficesatFosnavåg,andestimatedthattherewere15personsonboardthe“BourbonDolphin”.At19:04(7)thecompanyreportedthattheywereinplaceonthepremisesatFosnavåg.Atthesametime,itwasconfirmedthatthenumberofpersonsonboardwas15.
The“BourbonDolphin”hadherhomepor tatFosnavåginSunnmøre.SunnmørePoliceDistrictisthusthe LocalRescueCentre (Norwegianabbreviation LRS). After several enquiries about apossibleshipcasualty,at20:54(8)theLRScontacted the HRS, which confirmed the capsizingand stated that five persons were missing. TheHRSimmediatelyforwardedthecrewlisttotheoperationscentreinSunnmøre.
According to the police log, the HRS statedthat they had in fact alerted the local police,thoughthisdoesnotappearinthelogsofeithertheHRSortheLRS.
At21:14(8)theSheriffofHerøy&SandeMunicipalitywascommissionedbytheLRStoestablish contact with the company. Sheriff Per Otto
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Myklebust and Sergeant Detlef Sandanger proceededimmediatelytothecompany’spremisesatFosnavåg.Asearlyas21:15(8)theLRSwascontactedbytheDesignatedPersonAshoreinBourbon Offshore, Eli Oksavik. She stated that the
Managing Director was Trond Myklebust andgavethepolicethenecessarytelephonenumbers.Shealsostatedthatafullcatastrophesystemhadbeen initiated. Oksavik also informed the policethatthecompanyhadalistofallthenextofkin.
At 23:46 (8) Sergeant Sandanger from thecompanyofficesstatedthatthefollowingofthecrew had phoned home or to the company andconfirmedthattheyhadbeenrescued:GeirToreSyversen,PerJanVike,EgilAtleHafsås,Thomas ArnesenandKimHenrikBrandal.Alittlelater,at00:21on13April(8),Sandangerstatedthatthe
aforementioned persons plus Ånje Nilsen andØysteinSjursenwerenowinthehospitalinShetland.Noneofthemweresaidtobeseriouslyin juredphysically.
Sergeant Sandanger stated that it had been Able Seaman Per Jan Vike who had called thecompanyandgiventheinformation,sothatitwasfinallyconfirmedthatsevenofthecrewhadsur vived theaccident.At thesametime,Sandangerexpressedfrustrationthattheyhadsuchbigproblems getting information from the emergency
managementteaminLerwickandAberdeen.Asmentionedabove,itwasthesurvivorsthemselves who had called the companyand reported theirrescue. The Norwegian Foreign Ministry wascontacted,andtheywouldcontacttheNorwegianconsulonthespot.Onlya fewminutesaftertheidentity of the seven survivors had been confirmed,Sandangerstatedthatthenextofkinofthe survivors had been informed. At the sametimehestatedthatthreepersonswereconfirmeddead,butthathehadnotbeenabletoconfirmtheiridentity.
At00:30(8) theNorwegianconsul-generalinScotlandcontactedtheLRS.Hewantedtobeputintouchwiththeemergencymanagementteamin
Scotland,inanattempttoimprovetheflowofinformation.Shortlyafterwardstheconsul-generalreportedthatthepoliceinAberdeenwereapologisingforthelackofinformation,atthesametimeas the Norwegian police were given a contact
number.Callstothisnumberwerenotanswered. At 03:42 (8) the Sheriff of Herøy and SandestatedthatthecompanywouldsendoutaplanetoShetland. The Sheriff decided to send SergeantDetlefSandangertoShetlandasliaison.ThiswasdesiredbyboththecompanyandtheScottishpolice.ThedecisionwassanctionedbytheChiefofPolicethenextday.
At 08:15 (7) the British emergency managementteamtoldtheHRSthattheydidnotconsiderit necessary to have the helicopter continuesearchforthemissing.
At 17:02 (8) Sergeant Sandanger stated thattwodeceasedwereonboardtheplatform,whereasthethirddeceasedwasstillonboardoneofthe vesselsparticipating intherescueoperation(the“Viking Victory”). None of the dead had beenidentified. Sandanger, who was now in place inLerwick,wasabletostatethatdivershadagainsearchedformissinginthecapsizedvessel,withnoresults.
At 20:39 (8) Sergeant Sandanger stated thatthecoastguardhad,earlierintheafternoon,de
cidedthattheynolongerhadasearchandrescueactionforsurvivors,butasearchformissing.Thecorrecttimeforthecalling-offoftherescueoperation was 15:45 British time (Norwegian time16:45),sothatthefactthattheoperationhadenteredanewphasewasnotknowntotheLRSuntilalmostfourhourslater.ThesubsequentcommunicationbetweentheHRS/LRSandtheBritishauthorities concerned mostly the treatment of thedeceased–whowasresponsiblefortakingthemawayfromtherigandthe“VikingVictory”andbacktoNorway.Thenextofkin,thepolice,TransoceanandChevronallreactedtothefactthatthedeceasedwereleftaverylongtimeonboardthe“VikingVictory”andtherig.
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Chapter 11The salvage attempt
11.1 Introduction
Afterthe“BourbonDolphin”capsized,theemergency management team (Transocean Rather Emergency Response Team) was concerned to rescuesurvivors,searchforthemissingandsafeguardthe
rig.Sincetherigwasconnectedtothecasualtyviaabout 1,800 metres of chain, they were worriedaboutwhatmighthappentotherigwerethe“BourbonDolphin”tosink.At17:18tensiononmooringline2wasreadoffat170tonnes(4).Ordersweregiventoreadofftensionontherig’swincheveryfiveminutes,sothatanychangescouldbediscoveredquickly.Intime,onThursdayevening,theybeganalsotofocusontheconditionofthe“BourbonDolphin”afterhercapsize.Thefirstloggedinformationwasat21:11,andsaidthatthecasualtywaslying
deeper in the water. After midnight, on the earlyhoursofFriday13April,updatescamemuchfaster,atthemaximumtwiceanhour.
11.2 Log information on the “BourbonDolphin” until she sank
TheCommissionhas receivedseveral logs from Transocean,Trident andChevron,andanextensiveaccountbasedonloginformation.Whenthesalvageattemptistobeassessed,itisexpedienttoreproducethisinformationregardingtheconditionofthe“BourbonDolphin”afterthecapsizing. This was important information for the assessments undertaken by Smit, Transocean,ChevronandSOSREP.
The Commission has found the explanationspresentedbySmittobeexhaustive,andsawnoneedtoaskquestionsofaconfrontational,amplifyingorclarifyingnature.
Theinformationaboutthecasualty’sconditionanddevelopmentuptowhenshesankisobtained
fromthefollowingdocumentation:1. Towmasterlog,keptontherig,seeAnnex1,
Section5.1.
2. Ballastcontrolroomlog,keptontherig,see Annex1,Section5.4.
3. Transocean emergency response log, see Annex1,Section5.3.
4. Chronologicallistofeventsatsite,seeAnnex1,Section5.5.
5. JointaccountfromChevron,TridentandTran
socean.
As in thechapteron therescueoperation,referenceswillbegivensolelytodocumentnumber.
12 April
At17:10“BourbonDolphin”lay1,490metresfromtherig(5). At 21:11 “Highland Valour” reported that theDolphin’shullwaslyingdeeperinthewater(1).
At 22:30 “Highland Valour” reported that theDolphin’shullwasstillvisible,butthattherewaslessfreeboardthanwhenthevesselcapsized(1).
13 April
At01:08UnchangedconditionforDolphin(1) At01:38Unchanged(3) At02:31Stillunchanged(4) At03:04Unchanged(4) At04:02Unchanged(4) At04:32Unchanged(4) At05:11Unchanged(4) At05:36Unchanged(4) At06:00Unchanged(4) At06:40Unchanged(4) At07:15Unchanged(4) At08:05Unchanged(4) At 08:30 Grampian Frontier reported that there wasoilintheseaaroundthecasualty(4) At09:07Unchanged(4) At09:35Unchanged(4) At10:00Unchanged(4)
At10:30Unchanged(4) At11:05Unchanged(4)
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At12:03Unchanged,butmoreoilvisiblethanpre viously(4) At13:02Unchanged(4) At14:00Unchanged(4) At15:00Unchanged(4)
At16:00Unchanged(4) At16:32Unchanged(4) At17:13Unchanged(3) At17:32Thebowsarelyingabitdeeper(4) At 19:42 “Vidar Viking” took over monitoring ofthecasualty(4) At 20:17 “Subsea Viking” took over monitoringfrom“VidarViking”(4) At21:04Unchanged(4) At 22:00 The casualty had moved a few metres westwards,butotherwiseunchanged(4) At23:00Unchanged(4)
At 23:28 The casualty was moving slowly west wards(4) At23:59Unchanged,driftinghadstopped(4)
14 April
At01:00Unchanged(4) At02:00Drifted30-40mwestwards(4) At03:00Driftedalittlebackinaneasterlydirection.Otherwisenochange(4) At04:55Unchanged(4)
At07:00Unchanged(4) At07:57Drifted100-150meastwards.Otherwisenochange(4) At09:00Unchanged(4) At10:00Unchanged(4) At10:57“VidarViking”tookovermonitoringthecasualty.Otherwisenochange(4) At12:00Unchanged(4) At 13:00Drifteda fewmetreswestwards. Other wiseunchanged(4) At14:06Unchanged(4) At16:57Drifted70meastwards(4) At17:12Driftedanew30meastwards(4) At20:15Drifted10mwestwards(4) At21:40Thehullwasstillstable,nochange(4) At 21:58 “Subsea Viking” took over the monitoringfrom“VidarViking”(4) At22:20Thechainwassecuredin“OlympicHercules”’shark-jaws(4) At22:28Thechainwascut(4) At22:57Unchanged(4) At23:07Driftedslowlywest/north-west(4) At23:13“VidarViking” tookoverthepart of the
chainthatwenttotherig(4)
15 April
– At04:00Thecasualtywasnowdriftingawayfromtherig’smooringlines(pattern)(4)
– At 11:35 “Olympic Hercules” reported that
“BourbonDolphin”’sbowswerelower(1)– At13:55“BourbonDolphin”lyingevendeeper(1)
– At21:13Thehullwasnowfloatingvertically(5)– At21:15“OlympicHercules”freesthechain(5).
Everyone informed that “Bourbon Dolphin”hasnowsunk.
Betweenat13:55and21:13nomessagesareregistered.CaptainGrimAreBergtunofthe“OlympicHercules”testifiedthatonSundaymorningheconsideredthatthe“BourbonDolphin”wasslow
lysinking.
11.3 Events until the salvage contractwas signed on Friday 13 April
As will be seen from log data from 12 April at21:11(1),thecasualtywaslyingdeeperinthewater lateonThursdayevening thanshehaddone justafterthecapsizing.Aftermidnightnochanges werereported.
At02:20on13April(3)BjørnBergsneswasincontactwiththeTransoceanEmergencyTeamin Aberdeen.Hewasbroughtuptodateonthesituation.Hehimselfwasabletostatethattheinsurers would attempt a salvage operation for the capsizedvessel.Accordingtothelog,Bergsnesstatedthattheyhadnoconcreteplansyet.Herecommendedwaitingandseeinguntilitbecamelightanduntildivershadinvestigatedthecasualty.
InthecourseofthenightinvestigationsweremadewithaROVfromthedivingvessel“Subsea Viking”.At06:00(3) the“SubseaViking” reportedthatROVsearchingshowedthattheworkwireof the “Bourbon Dolphin” stretched down to adepthof225metres.Itwasconnectedbyaswivelandchain.
At 07:18 (3) the company informed Transocean that they had initiated collaboration withthesalvagecompanySmitSalvage.
At07:45(3)SOSREPRobinMiddletonspoketoTransocean.HehadbeencontactedbytheUKDepartmentforTrade&Industry(DTI),astheresponsibleauthorityforpollutionandsalvageop
erations.Middleton’sdeputywasalreadyenrouteto Aberdeen. The function of SOSREP is describedinSection11.5.
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11.4 Smit Salvage
Aftertheaccidentastandardsalvagecontractwassigned withSmit Salvage in The Netherlands. It
wasaso-calledLloyd’sOpenForm(LOF)contract, withtheadditionofaScopicclause thatincludesstandardratesforcalculationoftheconsiderationandsetsasidetheprincipleof“nocure,nopay”.SmitSalvageistheworld’sleadingsalvagecompany,withamarketshareofmorethan50%.It isaDutchenterpriseheadquarteredinRotterdam,but withanumberofbranchesworldwide.Thesalvagecontractwasformallymadewiththecompany,butit was the insurers who had chosen Smit. The“BourbonDolphin”wasinsuredwiththeNorwegian company Gjensidige. Gjensidige coversonly
thelossofthevessel.Asregardspersonalinjury,thecrewwerepartlycoveredintheNorwegiannationalinsurancesystem,andforaccidentinsurance withtheNorwegianShipowners’Association.GardhadP&I insuranceon thevessel.Theconnection withSmitwasestablishedontherecommendationoftheinsurers,andfurthercontactwithSmitwasat all times a collaborative venture between thecompany and the insurers. Bjørn Idar RemøysignedthecontractonbehalfofBourbonOffshore.
ReinderPeek,Smit’scontractofficer,hasstat
edthatthesalvagecontractwasformallymadeonFriday 13 April at 11:00. But as early as theeveningoftheaccidenttherewascontactbetweenthecompanyandits insurersandSmit.Smitimmediatelycommencedtheworkofassemblingasalvageteam.
JanvanderLaanwasdesignedsalvagemanagerbySmit’sheadofficeinRotterdam.ThiswasinthemorningofFriday13April.Smithadalreadybegunto prepareasalvageoperation beforethecontractwasformallysignedat11:00.Whenvander Laan arrived at head office in themorning,theplanningmeetingwasalreadyunderway.Thefirstthingthathadtobedonewastosetupasal vageplanforsubmissiontoSOSREPforapproval. Thereafter they could get going on mobilising asalvage team. There was good communication withSOSREP,whoatthispointintimewascollaboratingwithSmitinconnectionwiththesalvagingofacontainershipintheEnglishChannel.VanderLaanwasbriefedonthesearchandrescueoperation that had been in progress, and was stillcontinuing,followingthecapsizeofthe“Bourbon
Dolphin”.ViaSOSREPhealsoreceivedarelativelydetailedaccountof the circumstances aroundtheaccidentandthecurrentconditionoftheship.
At13:46(3)therewasaconferencecallinvolving SOSREP, Transocean, Chevron and Smit, at which thesituationwas reviewedandexplained. TheywerestillwaitingfortheresultsoftheinvestigationsofthecasualtybytheROV.Itwasexpect
edthatthesewouldbereadyinthecourseoftheafternoon.
11.5 SOSREP – Secretary of StateRepresentative for MarineSalvage and Intervention
TheoffshoreactivityintheUKSectorbelongsundertheDepartmentofTradeandIndustry(DTI).Inincidentsinvolvinganimminentdangerofpollution,ithasbeenfoundexpedienttoauthorisea
singlepersontoactonbehalfoftheDTI.ThisisthebackgroundtotheestablishmentoftheSOSREPfunction.SOSREPistomonitorandifnecessaryintervenesoastopreventorlimitdamagetotheenvironmentfrompollutionordangerthereof.SOSREPmayputtogetheraSalvageControlUnittoassisthim.Incaseswhereattemptsaretobemadetosalvagelostvesselsorequipment,asal vageplanshallbesubmittedtoSOSREPandapprovedbyhim.
Together with the Maritime and Coastguard
Agency,theDTIhasestablishedasystemfornotificationofSOSREPinincidentsthatinvolveadangerofpollution.TheDTIandSOSREPwerenotifiedofthecapsizingjustafter18:00onThursday12April.SOSREPRobinMiddletoncontactedhisdeputy,HughShaw.ShawwenttoAberdeenonFriday13AprilandestablishedhimselfwithhisSalvage Control Unit in the premises of Transocean.HughShawhasstatedthatat17:08aconferencecallbeganinwhichSOSREPandhisdeputy,plusTransocean,ChevronandSmit,participated.Aproposedsalvageplanwaspresented,atthesametimeasallthepartieshadtheopportunitytomaketheir assessmentofthesituationand what choices they were facing. According toHughShaw,asalvageplanwasapprovedbySOSREPat18:48.
11.6 The salvage plan
ThedraftsalvageplanwaspreparedintheafternoonofFriday13April.Accordingtotheplan,es
timatedtimeofarrivalonthefieldwasaboutmiddayonSunday15April.Thesalvageteamwastoconsistofafour-mandivingteam,ofwhichone
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manwasleaderandanothersalvagemanager.Inadditiontothe“Zeus”,whichwasatugboat,the“HighlandValour”wasalsocharteredon14April.
Theplandividedtheoperationinto11stages:1. Preparationoftheseparationofanchorchain
no.2fromthecasualty2. Installationoftowinggearonthecasualty3. Separationofthecasualtyfromanchorchain
no.24. Inspectionofthecasualty,ifpossible5. Increaseoftheairpocketsinsidethevessel,if
possible6. TowingofthecasualtytoCollaFirthwiththe
aidoftwotowingvessels7. Afullinspectionofthecasualtywithdivers8. Removalofbunkersandflammablesubstances
withequipmentforhotconnection
9. Preparationoftheturningoperation10.Turnthecasualtyover11.Returnthecasualtytoherowners
According to theplan, inallstagesof theoperationthenecessaryprecautionsshouldbetakentoavoidorminimisedamagetotheenvironment.Asregardsoilspills,aseparateplanwastobemadeforremovalofbunkersandflammablesubstances.Ifcircumstancessodemanded,theplanwouldbeadjustedalongtheway
One of Smit’s naval architects, Alex Gorter, was incontactwithDNVinorder toarrange formodelling of damaged stability. In parallel withthis,ReinderPeekofSmit’ssalesdepartmentwasincontactwiththetugboatbrokerswithaviewtoconsideringwhatresourceswereavailableinthe vicinity of the casualty and that could be charteredforthesalvageoperation.
Itwasquicklymadeclearthattwotugswouldbeneeded.Thefirstwouldbecommissionedtotransport salvage equipment, including diverequipment, that was cleared for dispatch fromSmit’s warehouse. For this purpose the tugboat“Zeus”,basedinDenHelder,wascharteredintheafternoon.Thisvessel wouldthereafterserveasdiversupportvessel.
Theothertug’sjobwastotowthecasualtytoasuitablelocationinShetland.Atthetimeoftheaccidenttherewereseveralotheranchor-handling vessels in thevicinity.Completeinformationwasacquiredaboutthe“OlympicHercules”,the“VikingVictory”andthe“HighlandValour”.Itwasconcluded that the “Highland Valour” was best
suitedtotheassignment.Smitconsideredthatthe vessel’sanchor-handlingequipmentontheworkingdeck,whichincludedagypsyforhandling76
mmchain,wasbestsuitedtothesalvageoperation.The“HighlandValour”wasnotavailableimmediately.Itwasstatedthatshewasgoingtoporttochangecrew,andthatsheneededtobunker.Shewasexpectedtobeavailableinthecourseof
16-20hours.Smitcalculatedthattheactualtowwouldtakeabout40hours.Thatwasassumingthatthecasualtycouldbetowedat2knots.
The salvage plan was approved by SOSREP.Noinformationhasbeenreceivedaboutanyob jectionsbeingmadetotheplan’scontent.
11.7 SCR –Special CasualtyRepresentative
At13:30onFridaymorning,SteffenSchultz,ofSTSMarineConsultinDenmark,receivedanenquiryfromGardP&IofNorway.HewasaskedtoundertaketheassignmentofSCR(SpecialCasualtyRepresentative)in connectionwiththesalvageofthe“BourbonDolphin”.ASCRistosafeguardtheinterestsoftheship’sownerinasalvageaction.UntiltheSCRisinplace,thesalvagemanagershallsenddailyreportstotheship’sowner.ThereafteritistheSCRwhoshallhavethedailyreport.Thesal vageplanshallbesubmittedtoanddiscussedwith
theSCR.AfterthisthesalvagemanagershallreportexclusivelytotheSCR.Thesalvagemanagerstillleadsoperationandisresponsible.IftheSCRdisagreeswiththesalvagemanagerhemaymakeaseparatereport.ThesalvagemanagershallifpossibleconsultwithSCR,andSCRshallbeempoweredtogivethesalvagemanageradvice.TheSCRshallendorsethesalvagemanager’sdailyreport.
11.8 The salvage team (minus thesalvage manager) goes to the
scene of the accident
The diving and salvage equipment was readiedandloadedonboardthe“Zeus”,whichsetcoursefortheaccidentsiteat19:25onFridayevening. ThesalvageteamhadpreviouslygonetoRotterdamairport,wheretheyhadcharteredaprivate jet.TheteamconsistedofsalvageinspectorEricde Graaf, deputy salvage manager Dennis vanHartenandthreedivers.TheyweretoflytoLer wickandbetransportedontotheaccidentsiteby
helicopter.SalvageManagerJanvanderLaanwastotrav
elfromRotterdamthenextmorning.
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Eric deGraaf could see that the “BourbonDolphin”was floatingwithher keel almost straight,perhapsalittledownatthebows,withafreeboardofoneortwometres.Thepropellerwasclearofthewateraftandtheazimuthpropellerwasclear
of the water forward. The vessel “Zeus”, which was carrying the diver and salvage equipment,had not yet arrived at the location, and so theteamcouldnotdoanythingotherthanacquaintthemselvesinpurelyvisualtermswiththesituationandthecasualty’scondition.
At10:50 thesalvage teamwentonboard therig.Duetothewaveheightthiswasnotwithoutits complications. As soon as the team was onboard,theyweregivenanupdatebytheOIM.Hegavethemdetailedinformationaboutthecircumstancesofthecapsizing.Itwasduringthisupdate
thatthesalvageteambecameawarethatthecapsizingoccurredduringthedeploymentoftheanchor,andthatitwasthereforepossiblethatanchorno.2wasonboardduringthecapsize.Theyhadhithertobelievedthatthecapsizingoccurredduringtherecoveryofanchorno.2.
De Graaf explained the salvage plan to theOIMandemphasisedthatSmit’sadvicewasthatthesituationaroundthecasualtyoughtnottobechanged until the salvage manager arrived andhadthechancetomakeanassessmentoftheca
sualty’scondition.Despitetheirobjectionstofreeingthe“BourbonDolphin”,theOIMmadeitclearthattheplanwastofreethechainlaterthatday, withtheapprovalofSOSREP.
Transocean was worried that the “BourbonDolphin”, if she sank or drifted against the rig,mightdamagethedrillingsiteordamagetherig’sothermoorings.Chevronsharedtheseconcerns.Moreover, the OIM maintained that the alreadypoorweatherconditionswoulddeteriorate.Inhisopiniontherewerenorealisticprospectsoftransferringpersonneltothehullofthe“BourbonDolphin”withaviewtofasteningapropertow.
De Graaf contacted Smit in Rotterdam andtoldthemthatTransoceanintendedtocontinue with their plan andwasgoing tocut the anchorchain.ForDeGraafitwasclearthatthesalvageplan would now consist of two phases. PhaseOnewouldbetofreethecasualtyfromtheanchor chain, and let her drift with the currentawayfromtherigwhileattachedtothe“OlympicHercules”.PhaseTwowouldbetoevaluatethecasualty’scondition,ifpossibleimprovebuoyan
cyandgetatowlineonboardsothatthe“HighlandValour”couldtowthecasualtytoYellSoundinShetland.
11.12 Development of the casualty’scondition on Saturday 14 April
Itmaybeseenfromthelogsthatinthecourseof
thisdaytherewasnochangeinthecasualty’scondition.Sometimesshedriftedabit,alternatelyina westerly and an easterly direction. There were,however,noreportsthatthebuoyancywaspoorer.Norwerethereanyimmediatechangesafterthechainwascutatabout23:00.
11.13 The “Bourbon Dolphin” is freedfrom anchor chain no. 2
Thedraftplantofreethe“BourbonDolphin”fromthe anchor chain was submitted by TransoceanandChevronintheearlymorningofSaturday14 April. The draft,with proceduresandrisk analyses,wassubmittedtoallinvolvedpartiesforcomments. This meant the “Olympic Hercules”, the“SubseaViking”, the “VidarViking”, the “TransoceanRather”,TridentandSOSREP.Allofthem, with the exception of SOSREP, participated in aconferencecallinwhichtheplanwasdiscussed.SOSREP approved the plan and wanted to givepermission for the cutting of the chain when it
had been takenaboard the “OlympicHercules”. Thiswasloggedat05:45(3)and(5).In the morning there was a conference be
tween the “Olympic Hercules” and Transocean,ChevronandTrident,inwhichplanswerelaidforhowthecasualtywastobefreedfrommooringlineno.2.Atthispointintimethe“OlympicHercules”wasstillunderchartertoChevron.At12:40(4)the“OlympicHercules”wastoldtodeployhergrapnel,andtheoperationtofreethecasualtywasunderway.
The plan was (according to Jason Bennet ofSmit) that the “Olympic Hercules” was to manoeuvreinsuchawaythatsheheldtheweightofthe chain neutral. That is to say, the “OlympicHercules”shouldnottowthecasualty,butholdherpositionconstantin relationtoit andpermitthe “Bourbon Dolphin” to continue drifting to wardsthenorth-east,awayfromtherig.
As mentioned above it was decided that the“OlympicHercules”shouldusehergrapnel,and withpositioninghelp fromaROV sheshouldgetholdofthechain,whichlayovermooringline3.
Forsafetyreasonsitwasdesiredtohaveasmuchchain as possible between the “Olympic Hercules” and the “Bourbon Dolphin”. Should the
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“Dolphin” sink during the operation, the “Hercules”wouldhavetoensurethattherisktoherselfwasminimised.
Thechainwasslowlytakenupontothedeckofthe“OlympicHercules”inabightandfastened
inbothshark-jawswithoutasafetybolt,sothatthe chain could be quickly released should the“BourbonDolphin”suddenlysink.Thentheconnection between the casualty and the mooringlinewastobecut.At21:40(5)the“OlympicHercules”hadgottenthechainupontohersternroller,andSOSREPthengavefinalpermissionforthechaintobecut.Thechainlengththatwenttotherigwassentovertothe“VidarViking”.Theportionofthechainthatwenttothe“BourbonDolphin” was retained onboard the “Olympic Hercules”. The “Vidar Viking” measured that there
wasabout60metres leftof the76mmchain.Betweenthe“BourbonDolphin”andthe“OlympicHercules”therewas860metresofchainand225metresofwirehangingdownfromthewinchofthe“BourbonDolphin”andfastenedtothischain. The length was measuredby the ROV from the“SubseaViking”.
The“BourbonDolphin”wasfinallyfreedfromtheanchorchainatabout23:00.Smithasmadeitclearthattheydidnotparticipateinthisoperationatall.Aspreviouslymentioneditwasimportantto
Smitthatnothingatallwasdone,outoffearthatthecasualty’sconditionwouldchange. The“OlympicHercules”handedovertherig’s
portionofthechaintothe“VidarViking”at23:13(4).The“BourbonDolphin”wasthendriftingalittleawayfromtheriginanorth-easterlydirection, withthecurrent,atthesametimeasthe“OlympicHercules”keptthedistancebetweenthetwovesselsconstant.Thereafterthe“Hercules”useddynamic positioning (DP) and kept the “BourbonDolphin” in position with minimum force. They were to lie and wait for the “Highland Valour”, whichhadbeencharteredbySmitandwasbringingpersonnelfromSmit.Theplanwasforthe“Va-lour”toreturntothefieldtotakeover,andthenbeginatow.Duetopoorweatherthe“Highland Valour”didnotgetbackonschedule.
11.14 The situation of the “BourbonDolphin” deteriorates
Inthemorningof15AprilCaptainGrimAreBerg-
tunconsideredthatthe“BourbonDolphin”wasabouttosink.Hehadseenthetrendinthecasualty’s buoyancy from pictures. Bergtun told the
Commissionthathecouldhavebeguntotowthe“Dolphin” atmidnightonSaturday. Hehad contactedtherigandaskedforpermissiontobeginthetow,sincehehadseenthatthe“Dolphin”wasbeginning to lie lower in the water. From the
charthesawthatabout50nauticalmilesaway,inaneasterlydirection,therewasadepthof200metres.InhistestimonytoH&SEinScotland,SOSREP’s representative Hugh Shaw stated that he wasnotawarethatBergtunhadproposedthatthe“OlympicHercules”couldattempttotowthecasualtytoshallowerwaters.
GrimAreBergtuntestifiedthathepresentedthesituationtoSmit’srepresentativeonboardtherig.Therepresentativehadconsentedtothe“Hercules” commencing the tow. According toBerg-tun,thishappenedatabout10:00.EricdeGraafof
Smithasstatedthatitwasdifficulttoconsiderorconcur with the proposal from Bergtun, sinceSmithadneithercontrolofnoraccesstothecasualty.Bergtunhasstatedthatshortlyafterthis,at10:20,hewastelephonedfromtherig(thetow-master)andtoldthatChevronhadnotgiventhegreenlighttostarttowing.Theyweretoldtostop.BergtunhastestifiedfurtherthatSmit’srepresentativecalledandexplainedthattherewasanongoingmeetingbetweenSmit,Chevron,Transoceanand theBritishauthoritiesaboutwhatwas tobe
done. They hoped that Smit would shortly takeoverthecharterofthe“OlympicHercules”fromChevronsothatthetowcouldresume.Bergtunhasalsostatedthatsometimeintheafternoonhe wascalledagainandinformedthattherewasstillno solution, but that the meeting was still inprogress.
In the afternoon there had been anongoingdiscussion between Chevron and Smit about whetherSmitshouldtakeoveraschartererofthe“Olympic Hercules”, which was attached to the“BourbonDolphin”bytheanchorchain.Smitwasnot prepared to take over the chartering of the“Olympic Hercules”. The salvage manager hadnotarrivedat theaccident site,andhadnothadan opportunity to evaluate the condition of the“BourbonDolphin”.Moreover,the“OlympicHercules”hadtakenoverthecustodyofthe“BourbonDolphin”againstSmit’sexpressadvice.Smitdidnothavecontrolofthedecisiontocuttheanchorchainandthesituationrelatedtothis.Nor wasthetowready.AccordingtoSmititwasimportanttoconsiderhowthetowlinkitselfwastobe,
and intheiropiniontheconnectionbetween the“Olympic Hercules”and the “BourbonDolphin” wasnotsuitablefortowingatsea.Theconnection
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wasaworkwirethatranfromthetoprollerattheforwardendoftheworkdeckandwasfastenedtoa length of the anchor chain, which had beengrappled, cut and attachedto the “OlympicHercules”.
Smit’s plan was to consider the condition ofthecasualtyandarrangeasatisfactorytowconnectiononthatportionofthecasualty’shullthatstuckupoutofthewater,perhapsviatheruddershaftsaft.Ithadbeenconcludedthat the“HighlandValour”was thevessel inthevicinityofthecasualtythatwasbestsuitedtotakeovertheanchorchainandtowthecasualty.InthecourseoftheSundaytherewasmiscellaneousconversationaboutwhetherSmitshouldtakeoverthecharteringofthe“OlympicHercules”.SalvageManager vanderLaanhasstatedthatalittleoveranhour
afterhehadarrivedatthecasualty,at19:40,he was told thatSmithadtakenoverthecharter ofthe“OlympicHercules”.
Due to the weather conditions prevailing atthe locationit wasneverpossibleforSmit’s personneltoundertakeaninspectionofthecasualty,neitherof theprotrudingpartsof thehullnorofthepartthatwasunderwater.
Bergtunhasstated thatin theeveningheinformedtherigthatthe“BourbonDolphin”wasintheprocessofsinking.Hehasalsotestifiedtothe
Commission that he could see no rationalgroundsforthe“OlympicHercules”notbeingallowedtocommencethetow.Hewasoftheopinionthattheywouldatleasthavemanagedtotowthe“Dolphin”intoshallowerwaters.Butherecognisedthatthetowcouldhaveacceleratedthedeteriorationofthecasualty’ssituation.Bergtunalsotestifiedthatnomeasurestostabilisethe“BourbonDolphin”weretaken.
11.15 Salvage Manager Jan van der
Laan comes belatedly to the field
SalvageManagervanderLaanleftTheNetherlands on the morning of Saturday14 April,andtravelled via Edinburgh to Lerwick in Shetland.BecauseoffoginShetlandtheplanewasdelayedandhedidnotarriveinLerwickuntil19:00ontheeveningofSaturday14April.Atthatpointtherestofthesalvageteamwereinplaceontherig;theyhadbeentransportedbythevessel“AnglianSovereign”.Duetofog,itwasnotpossibleforvander
LaantogethelicoptertransportouttotherigonSaturdayevening.
OnthemorningofSunday15Apriltherewasstillfog,anditwasthereforeuncertainwhenSal vageManagervanderLaancouldgetouttherig.Inthemorninghewastoldthattheearliestdeparturewouldbe10:30.Laterinthemorninghewas
toldthattherewereneverthelessnoprospectsofhelicopter departure in the course of the day.Once more he had to turn to the coastguard vessel “Anglian Sovereign”, which would transportthesalvagemanagerfromScallowayandouttotherig.
Inthecourseofthetripouttotheaccidentsite van der Laan was in telephonic contact with hiscolleaguesdeGraafandvanHartenonboardontherig.Theywereabletotellhimthatthe“OlympicHercules”hadinformedthemthatthesituation was steadily deteriorating through the day.
Thesalvageteamcouldnotmakeindependentobservationsbecausethecasualtyhaddriftedaboutfournauticalmilesawayfromtherig.
DuetotheweatherconditionsitwasnotpossibleforSmit’sdiverstoexaminethecasualtyatall. The vessel ”Zeus”, which had all the necessaryequipment,wouldaccordingtovanderLaan’sinformationnotbeatthesitebefore18:45.
At 18:30 Salvage Manager van der Laan arrivedattheaccidentsite.Heaskedthemasterofthe “Anglian Sovereign” to make a closer ap
proach to the casualty. Van der Laan observedthat the casualtywasfloatingdifferently towhathe had seen on pictures previously. When theyheld the planning meeting two days previously,the“BourbonDolphin”hadhadafreeboardof2–2.5metreandwasfloatingevenly.Hecouldnowseethatthesternhadoneortwometresoffreeboard,whereasthebowswerevisiblylowerinthe waterthanpreviously.Asareferencehehadtheazimuthalpropellerforward.Thishadpreviouslybeen quite visible, but was now wholly submerged. The “Bourbon Dolphin” was rollingheavilyinthewaves,whichheestimatedatabout4metresfromthesouth-west.
11.16 The “Bourbon Dolphin” sinks
At18:45vanderLaanobservedthatalargequantity ofairwascoming out of the “Bourbon Dolphin”.Hecouldalsoseethattherewasanoilslickaroundthecasualty.Shortlyafterwardshecouldsee the bow sinking deeper. Van der Laan dis
cussed with the master of the “Olympic Hercules”,whoaccordingtovanderLaanagreedthatthecasualty’ssituationwasdeteriorating.
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At19:40vanderLaanwastoldbySmitinRotterdam that the “Olympic Hercules” was nowhired for the salvage assignment. In a situation withpowerfulseaandwavesof threeor fourmetresbeatingovermostofthecasualty’shull,ac
cordingtovanderLaantherewerenorealisticprospectofattachingatow.Therewasnoprospectof diversbeingabletoworkbecauseoftherough seas and considerable current. In thecourseofthenexthour,vanderLaancouldwatchthe “Bourbon Dolphin” gradually sinking bowfirst.At21:15thevesselrightedherselfverticallyandthensank.VanderLaancalledupthe“Olympic Hercules” and asked him to free the chain, whichwasdoneimmediately.
Thecasualtysettledatadepthof1,140metres.FilmingwiththeROVshowsthatthe“Bourbon
Dolphin”sustainedconsiderabledamage,includingtothetankstructure,duetoimplosionand/or whenshehittheseabedwithgreatforce.Sheremainedinanuprightposition,listingmarkedlytoport.Thewirerunsoverthecargorailonthestarboardsideinasouth-westerlydirection.
11.17 Evaluation
Thefirsthoursaftertheaccidentthemainfocus
wasonrescuinganysur vivorsfromthecapsized vessel. As early as Thursday evening, however,therewascontactbetweenthecompany/insurersand Smit Salvage. Smit immediately started the workofplanningthesalvageoperation.
ItappearsclearthattwointerestswerediametricallyopposedtooneanotherafterSmitwasgiventheassignmentofsalvagingthecasualty.ChevronandTransoceanwantedtofreethecasualtyfrommooring lineno. 2as soon as possible, astheywereworriedaboutthesafetyoftherig,Foritspart,Smitwantedhertolieuntouched.InadditiontherewasSOSREP,whowastoaddresstheauthorities’interestinavoidingenvironmentdamage.
There wereseveral alternative coursesof action.Therescueoperationitselfcontinuedupto15:45onFriday13April.Itwas thenconsideredthattherewasnolongeranyhopeoffindingsurvi vors,andthecoastguardcalledof ftheactualrescuecomponentoftheoperation.TheCommissionconsidersitentirelynaturalthattheworkofcuttingtheanchorchaindidnotbeginaslongasthe
rescueoperationwasinprogress.Inasituation whereone is searching for the missing, and thecasualty is apparently lying stably in the sea, it
wouldnotbesensibletodoanythingwithoutbeing quite sure that the condition would notchange.Inthatcase,theywouldbefacingasituationinwhichthecasualtyconstitutedacleardangertotherigandcrew.
Nextitmaybeaskedwhetherthechainoughttohavebeencutassoonastherescueoperation was called off. The operation was terminated at15:45onFriday13April,andthevesseldidnotsinkuntil21:15onSundayevening.Providedthatthedevelopmentofthevessel’sconditionwouldhavebeenthesame,theywouldhavehadmorethan50hoursforthecuttingofthechainandtowingintoshallowerwaters.Theworkofcuttingthechainwas initiatedat12:40onSaturday14Aprilandwascompletedatabout23:00,thatistosay,thisoperationtookmorethantenhours.Smitcal
culatedthatthetowwouldtakeabout40hours.Itcannot be ruled out that the Bourbon Dolphin”couldhavebeentakenintoshallowerwaterifthepreparations for the tow had been initiated assoonas therescueoperationwascalledoff.Nor wouldtherehavebeenanythingtopreventworkingonasalvageplaninparallelwiththesearchforsurvivors.
ThepreparationofproceduresforcuttingthechainwerereadyinthemorningofSaturday14,at05:45(5).At23:00theworkofcuttingthechain
wascomplete.Therewerestill22hourstogobeforethe“BourbonDolphin”sank.CaptainGrim Are Bergtun stated in his testimony before theCommissionthathesawnorationalgroundswhythe“OlympicHercules”couldnotstarttowingthecasualtytowardsshallowerwatersassoonashis vessel had taken over the connection with the“BourbonDolphin”.Itisdifficulttodrawreliableconclusionsastowhetherthiswouldhaveprovenfeasible.Thetowing pointon the “BourbonDolphin”wasmidships,whichwasnotfavourable.
Whenthe“OlympicHercules”beganthetowon Sunday morning, the casualty had alreadystarted to sink. A successful salvage operation wasthenprobablyimpossible.
As mentioned above, Smit did not want anythingtobedonewiththecasualtyuntiltheyhadhad a chance to examine the vessel. Smit’s sal vageteam,andpar ticularlySalvageManagerJan vanderLaan,weredelayedbytheweatherconditions. This will hardly have been of any significanceforSmit’ssalvagesuccess.AccordingtoJan van der Laan, Smit’s vessel, with the diving and
salvageequipment,didnotarriveuntil18:45onSundayevening.Bythetimethatallthemembersofthesalvageteamandthevesselwiththeneces
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saryequipmentwerefinallyinplaceattheaccidentsite,itwasinanycasetoolate.
FromThursdayeveningandupuntilthechain wascutlateonSaturdayevening,therewereverysmall visible changes to the buoyancy of the
“BourbonDolphin”.Apartfromanobservationat17:32onFriday(4),thatthebowshadsettledalittledeeper,therewerenoreportsthatthecasualty wasfloatingmoreheavily.Norwerethereanyimmediate changes to the casualty’s buoyancy inconnection with the cutting of the chain.Whenthehullbegantofloatdeeperthenextday,the weatherhadbecomepoor.Noconclusionscanbedrawntotheeffectthatthecuttingofthechainacceleratedtheprocessthatendedwiththecasualty’ssinking.
TheCommission finds that it cannotcriticise
Smit’sassessmentthatitwasbesttoallowthecasualty toremainuntoucheduntilit hadbeenexamined and stabilised. After the “Bourbon Dolphin”settledratherdeeperintheseainthefirst
hoursaftershecapsized,shestayedinapproximatelythesameconditionuptoSundaymorning.
NordoestheCommissionfindreasontocriticisethechainbeingcutonSaturdayeveningwiththeapprovalofSOSREP.Again,thereisnoreason
tobelievethatthecuttingcausedchangesinthecasualty’sbuoyancy.TheweatherbecamepoorerthroughtheSunday,leadingtogreatermovementofthecasualty,whichgraduallybegantoemitairandtakeonwater.
Thechanceofgettingthe “BourbonDolphin”into shallower water would probably have beengreatestiftheanchorchainhadbeencutassoonas possible and a tow commenced immediatelythereafter, as Transocean and Chevron wanted.Butgiventhefactthatthiswasacomplicatedoperationinwhichthemarginsweresmall,italso
appearedsensibletoexamineandstabilisethecasualty as long as its condition appeared unchanged. Any criticism of Smit’s assessments wouldthereforehavethenatureofhindsight.
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Chapter 12Summing-up: causes and responsibility
12.1 Introduction
Anaccidentisoftenaresultofseveralcontributorycauses–bothdirectorproximateandindirectorunderlyingcauses,thatistosay,factorsthathavenotdirectlycausedtheincidenttotakeplace
buthavecontributedtotheincidentorthefailuretoavoidit.
Onthebackgroundoftheevidenceavailable,the documentation reviewed and the technicalandotherinvestigationsperformed,inthischaptertheCommissionwillundertakeananalysisofcauseandeffectinrelationtotheaccident.
Overandabovedescribingtheproximateandtriggeringcauseofthelossofthe“BourbonDolphin”,theCommissionwilldescribetheindirectcausesoftheaccident.Theseincludefirstthefac
torsthatcausedtheemergencytoariseinthefirstplace and then the factors that meant that theemergencywasnotavoided.
In the Commission’s view, the underlyingcauses are extremely important for and understanding of the entire course of events and notleastforfuturepreventivesafetyworkinthatpartofthepetroleumactivitythatdemandsinputfromseveralplayersincomplicatedsituations.
Aswillbeshownbelow,theCommissionisoftheopinionthatfailureinthehandlingofsafetysystemsonthepartofthecompany,theoperatorandtherigalikearemajorcontributoryfactorsinthecomingoutofcontrolof theoperationon12 April2007.Inaddition,weaknessesin thedesignmeantthatthevesselhadpoorstabilitycharacteristics,withouteithertheshipyardorthecompanyhavingclearlycommunicatedthistotheowners.Seenalltogether,systemfailureintheplayersatseveral levels meant thatnecessary safety barriersweremissing,wereignoredorwerebroken,sothatcrewandvesselwereexposedtoanuncontrolledrisk,resultingintheaccident.
12.2 The proximate and triggeringcause
Vessels that capsize must always have been exposedtoforcesthatweresoconsiderablethattherectifying forces in the vessel were not strong
enoughtopreserveorregainherstability. Whatforcesinthecapsizingsituationaffected
thevesselandwhatcounter-forcesthevesselwasabletorespondwitharedescribedinSection9.10.
Despite some discrepancies and minor disagreementsinthechronology,theactualcourseof events on 12 April seems clear. Statementsfromwitnessesarethuscompatiblewiththeregistrationsincomputerplots,logsandweatherobservations.
The vessel manoeuvredon instructions from
thetowmastertowardsthewest,onaheadingthatmeantthemooringlineattackingthevesselmorefromtheside.Theangleofattackofthemooringlinethusbecamerelativelyhigh(40/60°).Beforethisorderwasgiventhevesselhadalreadydevelopedapersistentlisttoportofabitlessthan5°. The first list appeared almost immediately aftertheinnerstarboardtowing-pinwasdepressed.Itisnaturaltothinkthatinthissituationthemaster wouldtrytochangethevessel’sheadingsothattheforcesfromthemooringlinecausingthelist were reduced.When thevessel, in consequenceof the first serious list, lost her propulsion andsteeringability onthe starboardside,it becamedifficulttomanoeuvrethevesselinsuchaway.Anewandmoreseriouslist,duetothetensionintheanchorline,couldnotthenbeprevented.
IntheCommission’sassessment,itisnotpossibletodemonstratethata single error,technicalor human, caused the accident. The accident isexplicableintermsofanumberofunfortunatecircumstancesinteractingandresultinginthelossofthe“BourbonDolphin”.
In the Commission’s opinion, the capsizingoccurredasaresultofanumberoffactorsthat
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hadaccumulatedataparticularpoint intimeon12April:• theweatherandcurrentconditions• thevessel’sstabilitycharacteristics• thevessel’scurrentloadcondition
• theuseofrollreductiontanks• theinitiallisttoport(lessthan5º)• anunfavourableheadinginrelationtoattack
fromexternaldynamicforces• changed point of attack from the weight of
chainaft(depressingofthetowing-pin)• powerfullisttoport• reducedmanoeuvrabilityduetoblackoutofthe
starboardengines• wrongunderstandingoftheabilitytorelease
thechainquickly.
ItiscleartotheCommissionthatitwasparticularlythechangedangleofattackfromthechain,togetherwiththevessel’sheadingandreducedmanoeuvrability,plusinfluencefromexternalforces,that,togetherwiththevessel’sstabilitycharacteristicsandcurrentloadcondition,madetheaccidentpossible.
12.3 Indirect causes of the emergency
Inorderto identifyandevaluatethefactors thatledtheemergencyarisingatall,itisvitaltotakeacloserlookatthevesselandattheworkoperationthevesselwasperformingwhentheaccidenthappened.IntheCommission’sopinionfourmainelementsstandout:
Inthefirstplace–design,construction,certificationandthecompany’soperationofthevessel,includingthemanningoftheconcreteoperation.
Inthesecondplace–conditionsonboardduringtheoperation.
Inthethirdplace–theplanningoftheanchor-handling operation, including requirements forthevessels.
Inthefourthplace–theimplementationoftheoperation.
12.3.1 Defects in the vessel and the company
The“BourbonDolphin”wasdesignedandbuiltasacombinedsupply,tugandanchor-handlingvesselandwasthefirstoftheA102design.Equipmentforallthesefunctionswasfittedonboard.
The vessel possessed all necessary certificatesandhadnodirectivesoutstandingwhenshecapsized.Thevesselhadfournon-conformances
intheauditofthesafetymanagementsystem,asdescribedinSection4.6.
Chapter 5 describes the vessel and the construction process. As mentioned above, there were weight changes to the vessel, and the dis
tance above baseline for the vertical centre ofgravitywasincreased.Duringtheshipyard’sfirstswingtest,inwhichthevesselwasloadedforoptimalstability,aheelangleof17wasregistered.Anewswingtest,withlowerspeedsandlessrudder,gaveasmallerheel.
The winches were located over three decks.Section5.6providesadetaileddescriptionofthe winchpackage.Thewincheshadapullingpowerof400tonnes.Thewinchpackagealsohadafunctionforemergencyrelease.AsalsodescribedinSection5.6,thevesselhadtheusualequipment
foranchor-handlingontheafterdeck–twoshark- jaws,eachwithapairofdepressibletowing-pins.
Thestabilitybookforthe“BourbonDolphin” wasapprovedbytheNor wegianMaritimeDirectorate.Thestabilitybook’sloadconditionsforanchor-handlingwerenotsubjecttospecialapproval, confer Section 5.4.1. It is,however, apparentfromtheexampleconditionsforanchor-handlingthatwithcertainforcesonthewinchtheshark- jaw/towing-pinscannotbeusedwithoutchallengingthevessel’sstability,seeAnnex1Section1.3–
extractsfromFinalStabilityManual,pages1-195and1-206.Itwasinteraliastatedthathaving300tonnesonthewinchwasonlypermissibleifdragonthevesselwaswithin0.5metresofthecentre-line.Useoftheshark-jawrequiredchainorwiretobeabout1.7mfromthecentreline.Itisnotdocumentedthatthevessel’sstabilitycharacteristics weresuchthattheequipmentcouldbeusedatitsfullcapacity.
Therestrictionswerenotcommunicateddirectlyandclearlyinthestabilitybookor inanyother waytothosewhoweretooperatethevessel.
Thecompanydoesnotappeartohaverealised whatsignificancethechangeofweightinthevesselhadforherstability.Therewasadialoguebetween the company, including Frank Reiersen,andtheshipyardregardingthevessel’sloadconditions.FrankReiersenwantedthepreparationofmore,andmorerealistic,loadconditionsoverandabovewhathadbeenpresentedbytheshipyard. AsfarastheCommissionisaware,thisdialogueceasedinSeptember2006,withoutfurtherclarification.Thecompanyought,however,tohavein
vestigatedthismoreclosely.Such important information as the fact thatrollreductiontanksoughtnottobeusedduring
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anchor-handlingdidnotemergeclearlyfromthestability book. Nor did the “Bourbon Dolphin”haveon-boardinstructionsfortheuseofrollreduction tanks as demanded by the NorwegianMaritimeDirectorate’sregulatorysystem.
Both the regular masters on the “BourbonDolphin”testifiedthattheyhadexpectedavessel with better stability characteristics. Use of bunkersandballasttanksinvariousoperationscouldbeachallenge.Arecurrentfeaturewasthattheyhad made it a habit to have lots of bunkers onboard in order togive the vessel good stability.CaptainHugoHansenhadexperiencedastability-criticalincidentwiththevessel,butthiswasnotreportedtothecompany.Therearenorequirementsabouttrainingintheuseofloadcalculator;butaslongastheloadcalculatorisavailableasan
on-boardaid,companiesoughttoseetoadequatetrainingroutines.
Thecompany’ssafetymanagementsystemisdescribed in detail in Section 4.3. As shown inChapter7,therewereanumberofweaknessesinthesystem.Theseconcerninpartthe establish
ment ofroutines,primarilytheprocedureforanchor-handling.Theabsenceofsuchaprocedurehelpedmaketheimplementationoftheoperationmoredemandingforthecrewandtoagreaterextentgovernedbyhappenstance.
Therewerealsodefectsinthecompany’sproceduresforfamiliarisation(induction)ofmasters,not least routines for overlap. The Commissionfinds that it merits perticular criticism that thecompanydidnotensurethatCaptainRemøyhadaperiodofoverlapbeforehetookuphisdutiesasmasteronboard.Hewastherebygivencommandof a vessel with which he was unfamiliar and acrewhedidnotknow.RemøyhadexperienceasmasterofanotherandbiggerBourbonvessel,butin the Commission’s opinion it is precisely thisbackgroundthatmayratherhaveledhimtomisestimate the vessel’s characteristics. The Commissionwouldalsonotethatthetimeallocatedforhandoverofsuchacomplicatedoperationwasnotsufficienteither.
AspointedoutinSection4.7.5,theofficersonthe bridge were relatively inexperienced in thekind of operation which the “BourbonDolphin”initiatedattheendofMarch2007,whichwasprimarilyduetothefactthatthecompanydidnothaveapolicyforidentifyinglevelsoftrainingoverandabovetherequirementsoftheSTCWConven
tion.Thelackofexperienceofanchor-handlingingeneral and deep-water operations with strongcurrentinparticularmayalsohelptoexplainthe
operationalchoicesofthe“BourbonDolphin”on12April2007,conferSection12.3.2below.
Therewerealsodefectsintheimplementationofthesafetymanagementsystemonboard.Thisconcerns primarily defects in the preparationof
riskassessments,whichdidnotcoverhazardsto whichthevesselcouldbeexposed.Nordidthecompany’sinternalcontrolman
agetodetectthefactthatnoprotectionagainstallidentifiedriskshadbeenerectedonboard.ItalsomeritscriticismthatDNVhadnotinpreviousauditspointedoutthefailuretoprepareaprocedurefor anchor-handling, since the ISM Code demandsaprocedureforkeyoperations.ThiscriticismisalsodirectedagainsttheNorwegianMaritime Directorate, which audits DNV. Questionsmay also be raised as to whether the non-con
formancesweresoseriousthatthe“BourbonDolphin”oughtnottohavebeenissuedwithasafetymanagementcertificatefollowingtheDNVaudit.
The “BourbonDolphin”wascertified for180tonnesincontinuousbollardpull.Onthemarketthevesselwaspresentedasa“DP2anchorhandlingtugsupplyvessel”with194tonnesinbollardpulland400tonnespullingpoweronthewinch.It wasstatedintheRMPthatatcertainstagesoftheoperation one might encounter forces that demanded a bollard pull ofover 174 tonnes. With
fulluseofthrusters,however,bollardpullwouldbereducedtoaslittleas125tonnes,asdescribedinSection5.5.
Whenthe vesselwas chartered, thecompanyundertook no technical assessment of whetherthevesselhadsufficientcapacitytocompletetheoperationinquestion.Charterofthevesselwas vested,accordingtothecompany’sorganisationalchart,inthemarketingdepartment.IntheCommission’s opinion, the presentation for marketpurposes involved a danger of the operator expectingtogetabiggerandmorepowerfulvesselthanheactuallyobtained.
Despitethefactthatthecompanyhadabrand-newvessel–withanewdesign–thatwastobeusedinademandinganchor-handlingoperationatgreatoceandepths,thecompanydidnotacquireinformationabouttheoperationandtherebyhadno chance of assisting along the way with concrete advice, instructions or support. The Commission finds that there was continuous contactbetweenvesselandcompanyintheformofdaily writtenreportsbye-mailandotherwisetelephone
conversations with company employees. Thecompanywasinformedthatequipmenthadbeendamagedanditwastakinglongerthanexpected,
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butitwasnotstatedbyanyonethattheoperation wasunusualorwasexperiencedasdifficult.
A briefing with review of the RMP was held with theoperator’s representative.Thecompanyhadnorequirementsorguidelinesforsuchmeet
ings.CaptainReiersenhadsigned the form thatconfirmed that the “Bourbon Dolphin” was tohavethefunctionofAHVC,intheRMPdesignatedas “assist vessel”.TheCommissionhas beeninformed that thiswasnotcommunicated tothecompanypriortotheaccident.
Thewinchsystemwascertifiedandtheemergency release function was thus in conformity withtheauthorityrequirements.Theemergencyreleasefunctionistime-consuming.TheCommissionhasuncoveredthefactthatnotonlytherele vant crew, but also other crews in the company
had the perception that the emergency releasefunction on the winch was a quick-release that would cause spontaneous and full exit of wire/chain/lastonthewinchimmediatelyuponactivation.IntheCommission’sopinionthismisunderstandingmayhelptoexplainwhythisemergencymeasurewasnottakenearlier.
12.3.2 Activity on board on 12 April
Sections8.1and8.2describethebriefingandthe
crewchange.Uptodeploymentofanchorno.2,theoperation was by and large performed in conformity with theRMP, though with the reservationsdiscussed in Section 8.3. It is thus clear that the“BourbonDolphin”wasusedatleastasmuchastheothervesselsandthatthedesignationAHVCdidnotinvolveanylimitationsinthekindofmissionsthevesselwasassigned,seeSection8.3.4.
The Commission has no information to suggest that there were problems of any kind onboard.Allthewitnessestestifiedthattherewasagood working environment, good contact andgoodworkingconditionsonboard.
The masterhas the paramountresponsibilityforthesafetyofthevesselandthecrewduringmaritimeoperations.Evenif theanchor-handlingmanualonboardwasnotaperfectaid,itappearedthatnothinginthismanualrelievedthemasterofhisresponsibilityforthesafetyofthecrewandthevessel.Thisinvolvesanundisputedrightanddutytohaltanongoingactivity,evenifthecompanyandothers,forexampletheoperator,wereto
object.Themaster’sordersare thusthe lasthumansafetybarrierforcrewandvessel.
Duringanoperationinvolvingseveralplayers,goodcommunicationandflowofinformationbetween them is of considerable significance. Allpartieshaveanindependentresponsibilityforensuringthatallavailableinformationiscontinuous
lyexchanged.ThisisstatedintheNWEAguidelines and is also pointed out in the anchor-handlingmanualforthe“BourbonDolphin”.
Onboardwereanumberofaidstothevessel’smanoeuvringandoperations,amongotherthingsaloadcalculator,ascreenshowingengineoperationsandnavigationscreensforusebythemasterorthedutyofficersonthebridge.Itwasthuseasytoreadoffanydriftawayfromthemooringline. Themostimportant informantsare,however,thecrewsonboard,whofromtheirworkstations–onthebridge,ondeck,intheengine-roomorbythe
winches – are continuously following externalconditions,thevessel’smovements,performanceandstresses.
TheCommissionmustfind thattherewasinsufficientunderstandingonthebridgeofthefactthat the engine-room several times warned thatthethrusterswererunningatfullpower,thattheyhad no more to give and that overheating wasfeared.Asearlyasaround15:00theFirstEngineeringOfficerwarnedthebridgethatiftheydidnotthrottlebackthethrusters,hewouldhaveto
cutthemouttopreventdamage.Inretrospect,itseemsdifficulttounderstandthatthiswasatnopointperceivedascriticalandcompliedwithonthebridgeorreferredontothetowmaster.The“BourbonDolphin”graduallyde velopedconsiderabledrift,whichthevesselcouldnotcompensateonitsownresources.Insteadofsuspendingtheoperation,thevesselchosetoaskthe rig for assistance with grappling the chain. The Commission will return to the rig’s role inthiscontextinSection12.3.4.
After the unsuccessful attempt at grapplingthechain,the“BourbonDolphin”wasinstructedbytherigtoproceedwestwards,awayfrommooringline3.AsdescribedunderSection9.9,theinnerstarboardtowing-pinwasdepressed,possiblyon the initiative of the towmaster. The measure was first considered on the “Bourbon Dolphin”,thereafterimplemented.
Thevesselalreadyhadalistof lessthan5°toport.TheCommissionisawarethatthiswaspartially compensated for by transfer of ballast betweentheportandstarboardtanks.Thechange
inpointofattackfromthestarboardtotheouterportpinhadcatastrophicconsequences.
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As the Commission interprets the situation,themasterandthechiefofficermust,duringthefirstlist,thoughtthatitwasstillpossibletoavoidthelossofthevesselbymanoeuvringheroutofthesituation,evenwithreducedcapacity.Proba
blyitwasthisthatCaptainRemøywasattemptinginthelastminutesbeforethecapsize,conferSection9.9.Thisissupportedamongotherthingsbythe fact that the witnesses observed the vesselmakingsomezig-zags,thattheywaitedbeforeactivating the emergency release function on the winch,thattheydidnotactivatetheAbandonShipalarmortakeotheremergencyprocedures.
Inretrospect,itisdifficulttounderstandwhytheoperationwasnotsuspended.Therewereseveralsituationsuptothecapsizingthat,seeninisolation,couldsupportsuchadecision.Andthereis
reasontoaskwhetherthecrewofthe“BourbonDolphin”wereawareoftheconsequencesofdepressing the towing-pin and at the same timebearinguptowestwards,sothatthechain’sangleofattackoutfromthevesselcausedapowerfulheelingtoport.
There is reason to believe that during thisphaseoftheoperationthevesseldidnotfulfilallthestabilityrequirements.
Theofficerson thevesselhad,however,hadseveralunusualexperiences.CaptainHugoHans
enwassurprisedbyanunexpectedlybigheelingduring a tow at Mongstad. Both Hansen andFrankReiersenfoundthattheyhadtohaveanunusual quantity of bunkers onboard topreservestability.Inadditionthecrewfoundthatthevesseldid not have the cargo capacity specified. ChiefOfficerGrimstadhadvisitedtheshipyardforthatpurpose,andinthismeetingheissaidtohaveremarkedthatnooneonboardunderstoodtheballastingsystem. Thesefactors suggest that theremusthavebeenuncertaintyonboardinrelationto the vessel’s hydrostatic characteristics. Thecompany did not, however, have adequate systemsfordetectingandmakinguseofthisexperiencesothatgoodoperatingroutinescouldhavebeenestablished.
12.3.3 Planning of the rig move, includingvessel requirements
The operator regarded and described the rigmove in the RMP as an ordinary rig move indeep water, that is to say, depths greater than
300metres.WestofShetlandthewaterdepthismore than 1,100 metres. This means that themooring system had to tolerate considerable
stressandfulfiltherequirementsoftheregulatorysystem.
In Chapter 6 the Commission evaluated theplanningoftheoperation.Theplanandtheprocedures contained weaknesses on a number of
pointsandlackedreferencetoassessmentsofriskin planning and performance of the operation. Thisappliedparticularlytoestimationofexpectedforces.TheCommissionhaspointedoutafailuretoincorporatesufficientmarginstotakeaccountofstaticanddynamicforcesonthemooringlines(chainsand wire)due toweather,windandcurrentduringrecoveryanddeploymentofanchors.Norwastheresufficientreflectionoverthefactthattheneedtorelievetherig’swinchesbyuseofatwo-boatmethodwouldcauseincreasedriskforthe vessels, which could have created greater
problemsthanitactuallydid. The Commission has also demonstrated that
theplandidnotcontainanyclearweathercriteria. Theoperator,therigcompanyandconsultan
cyfirmhadallocatedthevariousfunctionsandassignments inconnection with the planning. Thefocusoftheplanningappearstohavebeendirectedparticularlyattheneedsoftherig,itsmooringand safety. Over and above specifying requirements for bollard pull, there was little attentionpaidtothevesselsthatweretobeinvolved.
Selectionofvesselsappearstohavereflectedthe ships available in the area concerned whentherigmovewastostart.Thisinvolvesariskthat vessels too weak for the operation are both offeredandselected.Notonlytheoperator,butalsothecompanyhasaresponsibilitytomakearealisticassessmentoftheindividualvessel’ssuitabilityfortheconcretemission.Inamarketwithsmalltimemargins,fewvesselstochoosebetweenanddifferentday-ratesforbigandsmalleranchor-handling vessels, it is of particular importance thatthepartiesarerealisticaboutbothwhattheyaredemandingandwhattheyareoffering.
The RMP specified the towing power at 180tonnes.Theoperationwastobeperformedindemanding waters in which current, weather and windcouldofferbigchallenges.Mooringthatwasto be deployed in particular positions demandsthat the vessels master lateral forces. That the vesselsmustthenusethrustersformanoeuvringisobvious.Theplan’sanalysisoftheneedforbollardpullwasincompleteandgaveanover-optimisticpictureofexpectedforces.
Onbehalfoftheoperator,thevesselswereinspectedbytheStewartGroup(broker)andbytheoperator’s consultant (Trident) before the con
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tract was signed. The inspection appears to theCommissiontobesuperficial.Theoperator’srepresentativewasnothimselfonboardthe“BourbonDolphin”.Nordidtheoperatorseetoobtainingthevessel’sriskassessmentsbeforetheoper
ationbegan,orundertakeanycloserinspectionofthevessel’soperationalandexpertise-relatedcapabilitytoperformtheoperation.Therewasnocontactbetweentheoperatorandthecompany.
12.3.4 The implementation of the operation
Sections6.2and6.4dealwithkeyandmarinepersonnelwiththeoperatorandontherig.Section8.3providesabriefpresentationofthefactualimplementation of the operation up to12April. InChapter9theCommissionhasgonethroughthe
eventsofthedayoftheaccidentingreaterdetail. TheweathersituationisdealtwithinSection9.5.
Severalpeoplenoticedthatafterthelastcrewchange the “Bourbon Dolphin” was unpractisedandhadtobeguidedduringtheoperation.Theyspent more time on their operations than other vessels.Despitethis,thevesselhadbeenable tooperateunderprevailingconditionsuptothedayoftheaccident.
As mentionedabove, at several places in thereport,theoperationofmovingtherigwaslonger
and more demanding than originally foreseen.Equipmentwasdamaged,therig’swincheswereoverstrainedandtherewereseveralpausesduetoboth the weather and repairs to the winches. Itprovednecessarytousetwovesselsforworkoperations that under the procedure should havebeenperformedbyonevesselalone.Eveniftheprocedure was deviated from several times, thechanges were not made in conformity with theprocedures contained in the operator’s manualand theguidelines(NWEA)that thepartieshadagreedshouldapplytotheoperation.
The rig company is the duty-holder and theOIM is the duty-holder’s responsible officer onboardtherig.TheOIM’sprimarymissionisrelatedtodrilling,butthroughouttheoperationhehasparamountresponsibilityforaddressingtheoverallrisk.Therigcompanyhadtheresponsibilityofmoving the rig and, via the consultancy firm,hiredexternaltowmasterstoperformthatpartofthe job without their having participated in theplanning.TheoperatorhaditsMarineRepresentativeonboardontherig.Duringthelastphaseof
the operation, however, the same person performedthefunctionofboththerig’stowmasterandtheoperator’srepresentativeontherig.
Both the towmaster and the OIM have keyrolesduringarigmovethatinvolveanchor-handlingoperations.Thetowmasterhastheresponsibilityfordirectingthevesselstovariousworkassignments in the operation and ensuring that
theseareperformedandlogged.Fromhispositionthetowmasterhasaccesstonavigationaldata, weather data and means of communication withthevessels.TheOIMhasaccesstothesameinformation,butnoresponsibilityfordirectingof vessels.Assupremecommanderontherig,however,hehastheauthoritytostopanyoperationthatmightthreatenthesafetyoftherig.Thispresupposes that the OIM is kept continuously informed.
The very last phase of the operation was, intheCommission’sopinion,characterisedbymajor
safetyfailuresinseveralareas–notonlyonthe vessel, as described above, but also on the rig. Whereas the vessel was very active in her attemptstogetanchorno.2intotherightplace,therigadoptedapassiveobserverrole.Themostimportantfactorsare:• Thedriftingduringdeploymentofanchorno.6
was not evaluated and communicated to theOIM.
• Theoperationwasbeguninmarginalweatherconditions.
• Theoperationdidnotfollowthewrittenprocedureprescribedfordeploymentofanchorno.2.
• Driftingwasobservedfromtherigatanearlypoint, but the towmaster did not ask for anexplanation.
• Thedriftingincreasedwithoutanexplanationbeinggivenorrequested.
• Thecausesandconsequencesofthedrifting werenotconsidered.
• Therequestforassistancefromanothervessel wasgrantedwithoutriskassessment.
• Grapplingatadifferentstageoftheoperationthandescribedintheprocedure.
• Improvisedgrapplingwasunsuccessful.• Twovesselsalmostcollided.• The OIM was not givencurrent information
anddidnothingtokeephimselfinformed.
TheCommissionisof theopinion thatwindand waves by themselves made the weather conditionsmarginal.Incombinationwithanunexpectedlypowerfulcurrent,thedeploymentofanchor
no.2oughtnottohavebeeninitiated.InitssummarytotheCommissiontheconsultancyfirmTridentnotedhow,whendeployingthe
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sixfirstanchors,itwasnotexperiencedthatanyofthevesselsdrifted.TheCommissionwouldremark,however,thatinthedeploymentofthepenultimateanchor(diagonalanchor),thelargestofthevessels,the“OlympicHercules”,wasunable
to hold the line, sustained adrift of 730 metresand had to have assistance from the rig to getback on track. Given such an unexpected incident,itisincomprehensiblethattheydidnotstopandevaluatethecausesofdriftingbeforecontinuingonanchorno.2withavesselwithconsiderably less bollard pull. The rig also thought thatthecrewofthe“BourbonDolphin”werelessexperiencedinthiskindofoperation.
Around 16:40 the “BourbonDolphin” was instructedbythetowmastertoproceedwestwards,awayfrommooringlineno.3.Thisresultedinthe
vessel getting a changed angle of attack for themooringline,whichhadfatalconsequences.
TheCommissionshallnot,andcannot,decide whethertheoperator,therigcompany,theirhiredconsultancyfirmorpersonswhoperformedtasksforanyofthese,haveactedincontraventionoftheBritishregulatorysystem.Buteveniftherehasbeen nobreach of regulations, the Commissionfindsitdifficulttoacceptthattheoperator’srepresentativeontherig,whohaddirectcontactwiththevesselsduringtheoperation,didnottakethe
moralandhumanresponsibilityofassuringhimselfthatalsothecrewofthe“BourbonDolphin” werecomfortable andsafeduring the lastphaseoftheoperationandunderstoodthescopeoftheinstructions given and the measures proposed. Thisappliestoboththemeasuresinitiatedbythe vesselitselfandthetowmaster.
12.4 Why the emergency was notprevented
Nochainisstrongerthanitsweakestlink. Wherehumanbeingsareinvolved,experience
showsthatmistakesaremade.Thatiswhyitisnecessarytohavesafetysystemsthatdetecthumanerrorandmakesurethatitdoesnotleadtoaccidents.
The crucial and obvious precondition foravertinganemergencyisknowingthatsuchasituationactuallyexists.
Whenalistisdevelopingintoacapsize,thingshappenveryquickly.Therewillrarelybetimeto
initiateproceduressuchasevacuation,useofsur vival suits etc. It is therefore necessary that thepreventivemeasuresbetakenbeforeitistoolate.
Inthe Commission’s opinion,during the lastphaseoftheoperationanimportantsafetybarrier wasmissing, in that the functionsofTransoceantowmasterandChevronMarineRepwerevestedin the same person. In contradistinction to the
towmaster, whose responsibility is primarily theperformanceoftherigmove,theoperator’srepresentativewillhaveparamountresponsibilityforallthe playerswhomthe operatorhaschartered to workforhim.
IntheRMP,inthecompanies’manualsandintheguidelines(NWEA),boundariesaredrawnforthevariousplayers’roles,theirtasksandareasofresponsibility. Theanchor-handlingvessels havespecifiedduties,andthemasterhasthesupremeresponsibility for the vessel’s maritime activityduring the operation. In a complex operation,
however,itisrequiredthateverybodyalsotakeresponsibility for one another. The towmastershadlongpracticeandexperiencefromanumberofrigmoves.Intheirtestimonytheymadeitexpressly clear that operations must often besuspended–alsoatthedemandofthevessel–andthattheyhaveneverbeeninsituationswherethishascreatedproblems.
In his Marine Operation Safety Brief, which was distributed to the vessels in advance of theoperation,RossWatson,whowastowmasterupto
9April2007,emphasisedtheimportanceofthe vessels informing the rig immediately if somethingisnotproceeding“correctly”,andparticularlyunderlinedthatfromtherig’ssidethere“isneveranyintentiontoputpressureonyoutodoanythingthatisnotsafe”.
Sometimearound16:30,TowmasterSapsford wasunwilling torelease the“OlympicHercules”evenifthisvesselwasfinishedwithherwork.ToquestionsfromtheCommission,Sapsfordcouldnotprovideanyfurtherexplanationofhowhehadenvisaged using the “Olympic Hercules”. Thissuggests that the towmaster must have experiencedthesituationasdif ficultandunpredictable.Itmayseemasiftherig“hopedforthebestandfearedtheworst”.
TheCommissionhasnoreasontobelieveother than that the operation would have beenstopped had the “Bourbon Dolphin” requestedthis.IntheCommission’sopinion,thecrewofthe“BourbonDolphin”mustnothavebeenawareof what a dramatic situation was developing, untilthefirstrollhadactuallyoccurred.
No failures or weakness have been demonstrated,norhastheCommissionbeenabletouncoverany,inthetechnicalaidsforcommunication
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ornavigationontherigorthevessels.EveryonecommunicatedonthesameVHFchannelwithEnglishastheirworkinglanguage.Therewasthustime,spaceandopportunityforcontinuouscontactandfollow-up.
Both short-term drifting and deliberate manoeuvring away from the line occur during anchor-handling,forexamplebecauseofstrongcurrent.Thisisgenerallyseenasapartofthevessels’ choices and adjustments. But whencommunication and common understanding areemphasisedasvital,itisdifficultfortheCommissiontounderstandthattherewasnocontactfromtherigtothevesselforlongperiodswhenthevessel–withoutfurtherexplanation–driftedsteadilymoreawayfromthelineandovertowardsmooringline3.Whenthedriftwasaslengthyandcon
siderableashere,itcannotbeexplainedasapartofthevessel’sordinarymanoeuvring.Itisdifficulttoacceptthattherigwaiteduponeventsoutoffearof interferinginwhatwasthoughttobethemaster’s responsibility. The Commission wouldalsorefertothefactthatonthepreviousdaytherighadassistedthe“OlympicHercules”inadriftingsituationasdescribedinSection9.2.
ItistheopinionoftheCommissionthatneither the vessel nor the rig had understood therisk caused by the vessel – while thrusting or
heading in the direction of her anchor deploymentstationatthesametimeassteadilydriftingintheoppositedirection–gettinganever-morecriticallateralpointofattackfromthechaintension.Thechainlaypressingagainsttheinnerstarboardtowing-pin.Whenthiswasdepressed,thechanged angle of attack, together with the vessel’swesterlydirection,lackofstabilityandexternalinfluencefromthecurrentandwaves,causedthecapsize.
12.5 Deficient safety management
AstheCommissionhasseveraltimespointedout,toaconsiderableextentthereexistauthorityrequirements, regulatory systems, safety managementsystems,guidelines,agreements,plans,procedures,manuals and otherwritten materials ofrelevancetothecase.Thereisthusnoshortageofwrittenmaterialofboththeobligatoryandtheadvisory kind. The problem is, however, thatmuchofthismaterialisgeneralandstandardised.
The challenge is to get the individual player onanyleveltohaveownershipofthesafetyregulatorysystem,tounderstandit,identifywithit,imple
mentitinhisownactivityandliveuptoitinpracticalday-to-daylife.
As far as theCommissionknows, there haveneverbeencapsizingaccidentswithanchor-handlingvesselsthataredirectlycomparablewiththe
lossofthe“BourbonDolphin”.TheCommissiondoes, however, know of Norwegian-owned anchor-handling vessels being rebuilt in consequenceofpoorstability.
Inthelightofthefactthatthe“BourbonDolphin”wasabrand-newvessel,builtatarecognised shipyard with modern technical solutions,certifiedandapprovedbyNorwegianauthorities,regulation-manned with certified personnel andoperated together with other vessels under aknown procedure, it was initially difficult tounderstandhowthisaccidentcouldhappen.
In the report, however, the Commission haspointedoutthatanumberofsafetybarrierswerebreached.Thisappliedtothedesign,constructionandequipmentofthevessel,hercertification,hermanningandheroperations.Moreover,breachesof various safety requirements during the planning and the implementation of the RMP havealsobeenidentified.
Someofthesebreachescanhavebeendirectlycontributorytotheaccident.Othersafetybarrierscouldhavehelpedtopreventit.
In Chapter 3 the Commission reviewed thesafetyregulatorysystemforvesselsandcompany,generally and fortheoperation inquestion.Theoperatorandrigaresubjecttoacomprehensiveregulatory system, to be complied with also bythoseparticipating in ananchor-handling operation; see report from Research Fellow HanneSofieLogstein,Annex1,Part7andSection3.6.
The big challenge is to make the safety systemsoperationalatallstagesandinsuchawaythattheindividualfeelsownershipofhisportionofthem.Thenextchallengeisindismantlingtheboundaries between the individuals’ spheres insuchawaythatacommonunderstandingandhumancareisachieved,atthesametimethatthisisnot experienced as interference, micromanagementandsurveillance.
Becausethehistoryofthe“BourbonDolphin” was such a short one, only very limited experiencewiththevesselduringdif ferentworkoperationswasacquired.Norwastheretimetoacquireother than ordinary and elementary operationalexperience with the vessel. No two vessels are
alike,andthisonewasnotsimilartosomeofthecompany’s other vessels. As is usual, both the
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companyandthecrewwouldgainexperienceofthevesselastheygottoknowherbetter.
Lateralforcesexertedbymooringlinesduringanchor-handlinghavenotbeeninfocusinrelationtostabilityintheregulatorysystem,probablybe
causeitisnotusualforvesselstogetsofaroff-trackduringdeploymentofanchors.Neitherthecompany,therefore,noranyoneelsehadpaidparticularattentiontothis.
Adrillrigissurroundedbyasafetyzoneof500mwithspecialrequirementsofduecarefortraffic within the zones. No such safety zones apply tothemooringlines.Ifamooringlineisdisturbed,itmayhavedirectsignificancefortherig’smooringandtherebyitssafety.IntheCommission’sopinionitwasdefectsintherig’ssafetymanagementthat permitted the “Bourbon Dolphin” to drift
againstline3withouttherigcorrectingthis.
12.6 Liability
ItisstatedinthetermsofreferencethattheCommissionshallevaluatefactualcircumstancesthatcanbeenvisagedasjustifyingcriminalliabilityfor
individualsorotherliabilityinconnectionwiththeaccident.
Through the factual presentation of the circumstances surrounding theaccident, theCommissionhasilluminatedanumberoffactors.The
Commissionregardsthisreviewasasufficientbasisforauthoritiesandprivatepartiestoconsidererrors,negligenceetc.andtodecidewhetherthis will or should trigger liability incriminalorcivillaw.Thequestionsofliabilitywillotherwisepertaintothecourtsasthefinalinstance.
The Commission has nevertheless in somecontextsfoundreasonstobeclearinitscharacteristicsofthebehaviourofindividuals,enterprisesorinstitutions,withouttherebytakingapositiononwhethertheprovisionsofthecriminallaworothersanctionedruleshavebeencontravened.
Insofarasithasfounditnecessaryandexpedienttofulfilitstermsofreference,theCommissionhas to a certain extent also considered factorslinked to foreign enterprises and individuals. Thesearenotsubject toNorwegian jurisdiction.ItwillthereforebeuptotheBritishauthoritiestotake a position on whether the circumstancesshouldtriggeranyformofliability.
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Chapter 13Recommendations
13.1 Introduction
Boththe“ScandinavianStar”disasterin1990andtheCommissionofInquiryafterthelossoftheexpress catamaran MS“Sleipner” on 26November1999demonstratedanumberoffaultsanderrors
thatweredirectlyandindirectlyresponsiblefortheaccident.Evenifthetwoaccidentsweremateriallydifferent in origin, development and scope, theyshowedthe importance ofeverybodyworking inpassengertransportatseabeingawarethatoperatingpassengervesselsinvolvesaconsiderableresponsibilityforhumansafety(NOU2000:31,page146).TherecommendationsmadebytheSleipnerCommissionwereparticularlyfocusedonthis.
Neitherthevessel“BourbonDolphin”northecircumstances around the accident are directlycomparable with the two above-mentioned acci
dents.Wheresafetyatseaisinvolved,however,itisalwayspossibletolearnlessonsfromotheraccidents.
Duetothestyleofworkininternationalfora,ittakestimetoincorporatechangesintheconventionsassuch,whereasamendingamplifyingandadvisoryregulatorysystemsisafasterprocess.ItisinprinciplerightandimportantforNorwegianauthoritiestoendeavourtogetchangestosafetyrulesimplementedinternationally,becauseshippinghasaninternationalcharacter.Nevertheless,
when a need for new safety rules is uncovered,theNorwegianMaritimeDirectoratemustconsiderwhethertheneedissourgentthatthenewruleshouldbeintroducedasaspecialnationalrequirement until work in international fora has bornefruit.Generallyspeaking,weightyreasonsarerequiredbeforeNorwayintroducesspecialnationalrequirements torulesthathaveaninternationalorigin.
Traditionally, Norwegian authorities havebeenfreetoimposespecialnationalrequirements when they thought it necessary. Now, however,theEEAAgreementhasbecomeabarrierinthisarea.Theregulatoryareaofrelevanceforthelossofthe“BourbonDolphin”is,toasmallerextent
than other areas, for example passenger ships,subjecttoharmonisedEUrules.TheActNo.101of 17 December 2004 on European NotificationDuty nevertheless demands that proposals fornewtechnicalregulatorysystemsthatarenotharmonisedwithintheEEAshallbenotifiedtotheESAinaccordancewithaspecialnotificationpro
cedure.Certain of the recommendations below pre
suppose changes in the current regulatory system.Someoftheproposedchangesareintendedfor international implementation. Until suchchanges have been made, the Norwegian MaritimeDirectoratemustconsiderwhetheritisrealistictogetspecialnationalrequirementsenacted.Other changes are of a supplementary nature, where it is assumed that we will not come intoconflictwiththe internationalrules.Mostof the
recommendationsneverthelessapplytothepracticingofthecurrentregulatorysystem.In its report, the Commission has reviewed
andpointedtoanumberoffactorsthatmeanthatsafetybarrierswerebreached.Thisalsoinvolvesa direct challenge to be aware ofand deal withcriticalelements inany workoperation.The implementation of the Commission’s recommendationswillstrengthenthesebarriersinfutureoperations.
The“BourbonDolphin”wasbuiltandequippedtoperformvariousworkoperationsintheoffshoreindustry.Whentheaccidenthappened,shewasengaged,withacrewof14persons,inanchor-handlinginwaters1,100metresdeep.
PartofthetermsofreferenceoftheCommissionofInquiryintothelossofthe“BourbonDolphin” was to analyse factors of significance forpreventingtherecurrenceofsuchanaccidentinfuture. In this chapter the Commission will describemeasuresthatintheCommission’sopinionmayhelptoreducetheriskofseriousaccidents withanchor-handlingvessels.
AsfarastheCommissionknows,noincidentshave occurred with Norwegian anchor-handling vesselsthataredirectlycomparablewiththe loss
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The list arm for thehorizontal componentshallbecalculatedfromtheheightoftheworkingdeckatthetowing-pinstothecentreof thepropulsionpropeller,ortheaftlateralpropellerifthisis
deeper.Theheelingarmoftheverticalcomponentshallbecalculatedfromthecentreofthevesseltotheouteredgeofthesternrollerandwithverticalpointofattackintheupperedgeofthesternroller. Themooringlineshallhaveanangleofattackofminimum25°inrelationtothe vessel’slongitudinalaxisinthehorizontalplane. Theangleinrelationtotheverticalplaneshallbesetastheonethatgivesthe
biggestlistangleforthevessel.Ifthepower from themooring line islessthanthemaximumbollardpull,theangleshallbesetat90º.Undertheinfluence of forces from the mooring line,thevesselshallatmaximumhavealistangle that corresponds to a GZ valueequalto50%ofmaxGZ. Themaximummanageableforce frommooringlinesthatemergesthesecalculationswillbethevessel’scapacityforthistypeofoperation.
– If it isnecessary to ballast the conditions to achieve a given manageableforce, the ballast used shall form thebasisforballastinstructionsdedicatedtoanchor-handling.
KG-limit curves
SpecificKG-limitcurvesshallbepreparedforanchor-handlingoperationsthatintroducetwonewcriteria(inadditiontoexistingrequirementsforsupplyships).
Astaticmomentshallbeused, relatedto the vessel’smaximumvertical loadduringoperationof the winch. List arm shall be calculated asshown above. Under the influence of this moment,thevesselshallatamaximumdevelopalistanglethatcorrespondstoaGZvalueequalto50%ofmaxGZ.
Undertheinfluenceofthemaximummanageableforcefromthemooringline,acurveforlistmomentshallbecalculated.Listarmsforthever
ticalandhorizontalcomponentshallbecalculatedasshownabove.Undertheinfluenceofthismoment,thevesselshallatamaximumdevelopalist
anglethatcorrespondstoaGZvalueequalto50%ofmaxGZ.
The proposed requirements for stability willmeanthattheshark-jawscanbeusedunderallstabilityconditionsinthewholeareabetweenthe
outertowing-pins.
13.3.2 The stability book
Thestabilitybookmustcontaina supplementofcalculationsinlinewiththerecommendationsdescribedabove,subjecttotheapprovaloftheauthorities.
Underthecurrentregulatorysystem,itisarequirementthatthestabilitybookcontaininstructions“thatinarapidandsimplemannerenablethemasterofthevesseltoenjoypreciseguidance
abouttheship’strimandstabilityunderdifferentsailingconditions”.
The Commission has the impression thatthese instructions have been standardised andconsequently fail to communicate vessel-specificfactors. A vessel-specific content would make iteasiertosafeguardstabilityonboard.Thefollowingshallbedealtwithintheinstructions:– concreteoperationalrestrictions,– capacitiesforgivenoperations,and– otheroperationalfactorsofsignificanceforthe
vessel’sstability.
Operationalrestrictionsmayforexampleincludetheuseofrollreductiontanksandballasttanksin variousoperations.
Capacitiesforgivenoperationsmayforexampleincludemaximummanageableforcefromthemooring line during running-out and maximumcapacityforcarriageofdeckcargo.
Other factors may for example include theneed, during any unusual use of the winch, forspecial attention related to stability, demandingthatstabilityfactorsbestudiedmoreclosely.
13.3.3 Training/operations
Useofsimulatortrainingisapositivemeasureforraisingthelevelofexpertise,andisencouragedinthe training of personnel. The very best thing wouldbeforsimulatorstobevessel-specific.Simulator training should include variations in theforcesthatthevesselmustbeexpectedtohandleand provide relevant feedback to the operator
abouttheconsequences. The Commission would recommend to maritimeeducationalinstitutionsthattheyreviewex
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istingtrainingactivitiesinstabilitywithaviewtothese also addressing factors related to towingandanchor-handlingoperations.
It is also recommended that companies andthemaritimemilieuestablishastrongerfocuson
maintenanceofoperationalstabilityonboard.
13.4 Design and certification
The Commissionhas considered, but not foundreason to propose, design changes to existing vessels, for example an increase inbeamor theconstructionof“buoyancyboxes”orotherdevicesthatcanhelppreventcapsizing.TheCommissionregardsitsproposalsforstability,planningandtheimplementationofanchor-handlingoper
ationsassufficientinthattheyarefocusedonpreventing this type of critical situation fromarising.
13.4.1 The bollard pull certificate
AlistoftheNorwegianfleetoperatingasanchor-handling vessels shows that it includes somesmallervessels,i.e.vesselswithcertifiedbollardpull under180 tonnes. It is therefore importantthatthecompanieshavearealisticunderstanding
ofthesevessels’realcapacitiesandlimitationsundervariousoperationalconditions.Inordertocertifythatthevesselhasamini
mummanoeuvrability,thebollardpullcertificateshouldindicatetwokindsofeffectoutput:first,itshould specify a maximum continuous bollardpullthatcanbeachievedbyuseofthevessel’smain propeller alone. Second, it should registeraneffectoutputinwhichthereductioninbollardpullwithfullloadingoftheaxlegeneratoristakenintoaccount.
13.4.2 Testing of the emergency releasesystem
Before installation, the functions of the winchpackageshould be tested with maximumoperational capacities. Certification on the basis of atypeapprovalcanverifysuchatest.Thisistoensuretheequipment’sfunctionalityinalloperationalloads.TheCommissionwouldasktheNorwegian Maritime Directorate to consider requirementsforaquick-releasefunction,perhapsina
modifiedversion,foruseinasituationinwhichcrew and vessel are facing a clear and presentdanger(casualtysituation).
13.4.3 Certification of winch operator
Thelossofthe“BourbonDolphin”hasuncovereda consistent lack of understanding of the emergency release function. The STCW Convention
makesnoqualificationrequirementsforwinchoperators.Inanyuseofthewinch,theoperatorisakeyplayer,anditisimportantthatthispersonis well-qualified. Requirements ought to be madethat winch operators undergo formal training,preferablyincollaborationwiththemanufacturer.Certification of winch operators should also beconsidered.
13.4.4 Direct emergency exit from theengine-room
The“BourbonDolphin”hadinallfiveemergencyexits,ofwhichfour(twooneitherside)lefttheareaunderthemaindeck.Thiswasinconformity with the requirements of the regulatorysystem.Inthelossofthe“BourbonDolphin”thechiefengineer,thefirstengineeringofficerandtheelectrician perished. They were probably in the engine-room.TheCommissionhasreceivedasuggestion fromthenext of kin to theeffect that adirectemergencyexitbecreatedfromthebottomoftheengine-roomthatcanbeusedinacapsize
wherethevesselislyingupsidedown. TheCommission thinks the suggestion is interesting.Itdoes,however,involvetechnicalandpracticalchallengesthatdemandfurtherprofessional evaluation. The Norwegian Maritime Directorate,incollaborationwiththeindustry,isrequestedtoconsiderthesuggestionfurther.
13.5 Equipment
13.5.1 Rescue floats
Whentheshipcapsizedonlyoneofthesixrescuefloats released immediately. Subsequent observation of the casualty showed that a further fourfloatswerereleased,whilethesixthwasreleased,butiscaughtinthevessel.Similarreleasemechanismshavesincebeentestedwithgoodfunctionality. There is therefore reason to believe that thismechanismfunctioned.
Sinceonlyonefloatcametothesurfaceafterthe capsize, the placement or installation of the
floatsinthecradlesprobablypreventedthemfloatingup.Thevesselremainedupsidedownforthreedayswithouttheremainingfloatsbeingfreed.The
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Commission considers that requirements shouldbe made for placement that would ensure thatfloatswerefreedevenwhenthevesselisinanupside-downcondition.Itshouldalsobeconsidered whether current installation requirements for
floatsaresufficientforvariouscasualtysituations.
13.5.2 Survival suits
The“BourbonDolphin”hadsurvivalsuitsplacedinallcrewcabinsandatthevariousworkstations. Thevesselwasthusequippedwithmoresurvivalsuits than the regulatory system demands. TheCommissionhassinceevaluatedthefunctionalityofequivalentsuitsandnotesthatthesuitsmaybedifficulttouseinanevacuationsituation,amongother things because their footgear is not very
user-friendly.Particularlywhenavesselislisting,itmaybedifficulttomove.Thebetterthefunctionality,thelowerthethresholdwillbefordonningthesuitin anemergency.In the lossofthe“Bourbon Dolphin” only life-jackets were used. The Commission would request the NorwegianMaritimeDirectorate to take an initiative to improvethesuits.
13.5.3 Emergency transponder
The emergency transponder was placed on the wheelhouse roof. As far as the Commission isaware, the emergency transponder failed to releasewhenthevesselcapsizedandfloatuptothesurfaceasintended.Sincethereweremanyvesselsinthevicinity,thiswasofnosignificancefortherescueoperation.Withoutvesselsintheimmediatevicinity,signalsfromsuchatransponder wouldhavebeenofcrucial significanceforrapidlocationofthecasualty.TheCommissionisawareoftheproblemsrelatedtoreleaseofemergencytransponders, andwouldrequest theauthoritiesto evaluate the placement and release mechanismsofsuchtransponders.
13.5.4 Voyage recorder
TheIMOhasintroducedrequirementsforvoyagerecordersforvesselsover3,000tonnes,enteringintoforceon1January2008forexistingvessels.IntheCommission’sopinionsucharequirementshould be introduced also for rigs and smaller vessels.Soundrecoverycansecureimportant in
formation, for example documentation of the instructions issued by the towmaster. It can alsomake important contributions to clarification of
other situations that arise, for example delays,lossofequipmentandsoforth.
13.6 Requirements for the company’s
safety management
InChapter4,theCommissionuncoveredseveralsafetydefectsinthecompany’smanagement.Thegeneral impression isthattheproblemdoesnotlieintheregulatorysystem’srequirements,butinthe company’s implementation of the requirementslaiddown.Thereisreasontobelievethatothercompaniesmayalsohavepotential for improvementinmanyofthesameareas.ItisthereforeachallengebothtotheNorwegianMaritimeDirectorateandtheclassificationsocietiesthatact
onbehalfoftheauthoritiestofollowupthesemattersinsubsequentauditsandtherestofthestrategicsafetywork,sothattheISMCodecanbebettercompliedwithinfuture.
Itisvitalthattheindividualcompanyhasa“living”safetymanagementsystem.Thesystemshallandmusthavearealcontentthatisimplementedpracticallyinday-to-dayoperationsonboardtheindividualvessel.
Anchor-handling is demandingandrisky. Theriskassessmentshavebeenparticularlyrelatedto
hazardousindividualoperations.Riskassessments, whichgenerallyfollowafixedformat,withcompletionof various forms,have firstand foremost focusedonthedangersofworkingondeck.Variousriskshavebeenhandledbymeansofuseofequipment,prohibitionsonbeingondeckduringwinchoperations,manoverboard,andsoforth.
Theassessmentsmustalsoembracethe risktowhichthevesselcanbeexposed.Duringrecoveryanddeploymentofanchors,thevesselwilloftenbeaffectedbygreatforces.TheCommission’sinvestigationshavediscoveredthatlargepartsoftheindustryhaveapparentlyfailedtotakeintoaccountintheirriskanalysesthatthe vessel as such
may be exposed to a considerable safety risk. Theyhavethereforefailedtomakeuseofallavailableaidstoforeseeandavertsituationsthatcanchallengethesafetyofthevessel.
Companies should moreover ensure that thecrewsarecompetenttoperformriskassessments.
13.6.1 Vessel-specific anchor-handling
procedure Anchor-handlingproceduresoughttobepreparedbythecompanies,andtheyoughttobevessel-spe
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NOU2008:8 141 Thelossofthe“BourbonDolphin”on12April2007 Chapter13
cific.Proceduresshouldalsoincluderequirementsforthe crew’sundertakingof assessments ofexpectedmooring-lineforcesasdescribedintherigmove procedure. For further indication of whatsuchaproceduremaycontain,seeSection4.7.3.
13.6.2 Overlap/familiarisation/handover
Safetymanagementsystemsshouldhavebarriersthatmeanthatamasterwhohasnotpreviouslybeenonboardavesselisgivenacertainformofoverlap and familiarisation (induction). It is notsufficientthatthemastercomesfromanotherofthecompany’svessels.
Inthesameway,itisimportantthatcompaniesandoperatorsfacilitatetheallocationofsufficient time for handover in a crew change. The
crewchangesmustensurethatthereistimeforasufficientreviewnotonlyof thevessel’sandtheequipment’stechnicalcondition,butalsoforinformationabouttheoperationwithwhichthevesselisinprogress.
13.6.3 Identify need for qualifications
Anchor-handlingisademandingmaritime operationandmakesrequirementsforextendedexpertiseincomparisonwithordinarysupplyactivity.
Ananchor-handlingoperationincludescomplicatedwinchoperations,connectionofheavyequipmentandmasteryofbigexternalforces.Whenanchor-handling is to be done in great waterdepthsunderchallengingsea,current,andwindconditions,itdemandsexpertisefarbeyondtheSTCW Convention’s minimum requirements. Ofparticularimportanceisahighlevelofexpertiseonthepartoftheseniorofficersofthewatchonthebridge(themasterandchiefofficer)tohandlesafeoperationofthevessel.Anylackofexperiencemustbecompensatedforbyaddingextraexperiencedpersonnel.
Safe anchor-handling also makes requirements for qualifications, among other things intheuseofloadcalculatorandothercomputerprograms,includingweightandpowercalculations.Such expertise and qualifications should be definedinacompany’ssafetymanagementsystem.
Companies must also ensure that time andmoneyareallocatedtotheimplementationofsufficient training and expertise enhancement intheseareas.
13.7 POB lists on departure offshore
Duringtherescueworkaftertheaccidentitwasdiscoveredthatduty-holderandtheoperatordid
not know how many people were on board the“BourbonDolphin”andwhotheywere. When a vessel is contracted, the companies
mustthereforeensurethattheoperatorandduty-holderatalltimeshavecompletelistsofthecrewsontheindividualvessel.Thelistsmustbecontinuouslyupdatedelectronically.
13.8 Planning of the rig move
Theoperatorhastheparamountresponsibilityforthesafetyoftheentireoperation.Rigmovesmustbeplannedandimplementedpursuanttoapplicablerequirementsandguidelines.Theproceduremustreflecttherealisticforcestowhichthevesselscanbeexposed.Theymustmakesurethatsufficienttimeisallocatedtopreparationsbeforetheoperationcommences,sothatthevesselsareguaranteedthenecessaryunderstandingofwhatitinvolves.
All offshore operations are very expensive. Timeisthusacriticalfactor.Itisimportantthatfor
example the weather requirements are clearandunambiguous,sothatnodisagreementarisesasto whenanoperationcanbeinitiatedorsuspended.
Theproceduremustbeoperation-specificandeasyforthosewhoaretocarryitouttounderstand.
The Commission has discovered that no explicitriskassessmentswerepreparedfortheoperation.Useofriskanalysesintheplanningphaseestablishes safety barriers. These many be of atechnical,operationalandexpertisenature.
13.9 Execution of the rig move
Demandforefficiencymustneverbeattheexpenseofsafety.
Intheimplementation,safetyandcoordinationmustbesubjecttocontinuousevaluation.Itisimportantthattheindividualvesselandnotleasttheoperator has insight and understanding of whattaskscanbeimposedontheindividualplayeronthebasisofthevessel’scapacityandthecrew’s
experience.
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142 NOU2008:8
Chapter13 Thelossofthe“BourbonDolphin”on12April2007
13.9.1 Start-up meeting andcommunication
Under the NWEA guidelines a start-upmeetingshouldbeheldinadvanceoftheoperation.The
guidelines do not contain any further requirementsastowhoshallbepresent.InSection61AoftheNorwegian OLFguidelines,however, itisrecommended that operational personnel fromtherig,theoperatorandthevesselsmeet,butthispracticeisnotalwaysfollowedontheNorwegianShelf.TheCommissionconsidersthatitmustbeamandatoryrequirementthattheoperatorensuresthat the necessary time is allocated for a jointmeetingonshorebeforetheoperationcommences.TheRMPshallbesubmittedtothevesselandthecompanyinadvanceofsuchameeting.
Reviewofhazardfactors,previousexperiences,weatherandcurrentconditionsandcoordinationoftechnicalchallengesrelatedtotheoperationarenaturalagendaitemsforsuchameeting.
Operatorsmustensurethatriskanalysesarepreparedbythevesselsbeforetheystarttheoperation,whichwasnotdoneinthiscase,butwhichfollowsfromtheNWEAguidelines.Therigmustalsogetaccesstotheanalyses.
Communication between the vessels and therigisoveranopenVHFchannel.Allinvolvedhave
accesstothischannel.Theworkinglanguageshallbecommon.Itisimportantthatcommunicationbeusedactivelyandthatwhatissaidisunderstoodbyall.Communicationisimportantforcreatingtrustandapositiveattitude,andcanhelpeveryonetofeel secure during the operation.The towmasterhasakeyroleinthis,butthemastersandofficersonthevesselsarealsoimportantcontributors.
According to areport from theDanishCommissionofInquiry(theDanishMaritimeAuthority),afterthe“StevnsPower”accidentit wasdiscoveredinteraliathattheroutinesforsafetycooperationduringtheoperationweredefective.
13.9.2 Tandem operations
Whentwoormorevesselsareworkingtogetherduringanoperation,itisnotsufficienttofocusonthesafetyoftheindividualvesselalone.Theves
selsarefacingdifferentchallengesandrequirements.Atthesametime,theyaredependentonone another to carry out the operation. In thisformofoperationstheindividual’sareaofresponsibilitycannotberestrictedtohisownvessel.
13.9.3 Attention zones for running-out ofanchors
An attention zone should be introduced alongmooringlinesthatindicateamaximumdistancethat the vessel shall observe when running out
anchors.Ifthezoneisviolated,thevesselmustreporttotherigandexplainthecause.Atthesametime, the towmaster should bemandated to demandanexplanationofthesituation.Ifthevessel, withnormaluseofthrusters,isunabletokeepinsidethezone,measuresshallbeobserved.The width of the zone and what measures are to betakenmustbeapparentfromtheRMP.
13.10 Duty of notification of maritime
accidents outside Norwegianterritory
TheCommissionisawarethatNorwegianauthoritiesarelookingmorecloselyatrequirementsfora duty of notification in connection with contra ventionsofChapter18of theMaritimeAct.TheCommissionwillleaveittotheauthoritiestoconsiderthescopeofthisdutyfurther.
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Norges offentlige utredninger
2007 og 2008
Statsministeren:
Arbeids- og inkluderingsdepartementet: Om grunnlaget for inntektsoppgjørene 2007.
NOU 2007: 3.Ny uførestønad og ny alderspensjon til uføre. NOU 2007: 4.
Barne- og likestillingsdepartementet:Kvinner og homofile i trossamfunn. NOU 2008: 1.Kjønn og lønn. NOU 2008: 6.
Finansdepartementet:Meglerprovisjon i forsikring. NOU 2007: 1. En vurdering av særavgiftene. NOU 2007: 8.Om tiltak mot hvitvasking og terrorfinansiering. NOU 2007: 10.Individuell pensjon. NOU 2007: 17Kulturmomsutvalget. NOU 2008: 7
Fiskeri- og kystdepartementet:Retten til fiske i havet utenfor Finnmark.
NOU 2008: 5.
Fornyings- og administrasjonsdepartementet:Offentlig innkreving. NOU 2007: 12.
Forsvarsdepartementet:Et styrket forsvar. NOU 2007: 15.
Helse- og omsorgsdepartementet:Fordeling av inntekter mellom regionale helseforetak. NOU 2008: 2.
Justis- og politidepartementet:Lovtiltak mot datakriminalitet. NOU 2007: 2.Frarådningsplikt i kredittkjøp. NOU 2007: 5.Fritz Moen og norsk strafferettspleie. NOU 2007: 7.Rosenborgsaken. NOU 2007: 9.Den nye sameretten. NOU 2007: 13.Samisk naturbruk og rettssituasjon fra Hedmark til Troms. NOU 2007: 14.Ny skiftelovgivning. NOU 2007: 16.
Fra ord til handling. NOU 2008: 4Bourbon Dolphins forlis den 12. april 2007.NOU 2008: 8.
Kommunal- og regionaldepartementet:
Kultur- og kirkedepartementet:
Kunnskapsdepartementet: Formål for framtida. NOU 2007: 6Studieforbund – læring for livet. NOU 2007: 11.Sett under ett. NOU 2008: 3
Landbruks- og matdepartementet:
Miljøverndepartementet:
Nærings- og handelsdepartementet:
Olje- og energidepartementet:
Samferdselsdepartementet:
Utenriksdepartementet:
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