Part one report on the collision on 8 November 2018 between the frigate HNoMS Helge Ingstad and the oil tanker Sola TS outside the Sture Terminal in the Hjeltefjord in Hordaland county

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Description

The Accident Investigation Board Norway (AIBN) and the Defence Accident Investigation Board Norway (DAIBN) has together with the Marine Safety Investigation Unit of Malta and the Spanish Standing Commission for Maritime Accident and Incident Investigations (CIAIM) conducted a joint investigation of the collision between the frigate HNoMS Helge Ingstad and the oil tanker Sola TS.

The part one report contains the results of the Accident Investigation Boards Norway’s investigation of the sequence of events up until the time when the collision occurred. The AIBN’s investigation has shown that the situation in the Hjeltefjord was made possible by a number of operational, technical, organisational and systemic factors. The Accident Investigation Board Norway submits a total of 15 safety recommendations based on the investigation of the sequence of events leading up to the collision.

Summary report for download.

 

The frigate HNoMS Helge Ingstad and the tanker Sola TS collided in the Hjeltefjord in the early hours of 8 November 2018. The frigate had 137 persons on board with a mix of conscripts and permanent crew. A total of seven watchstanding personnel were present on the bridge, including two trainees. The tanker Sola TS was operated by the Greek shipping company Tsakos Columbia Shipmanagement (TCM) S.A. There was a total of 24 persons on board. The bridge was manned by four persons, including the pilot.

HNoMS Helge Ingstad sailed south at a speed of approximately 17–18 knots with the automatic identification system (AIS) in passive mode, i.e. no transmission of AIS-signal. The frigate’s bridge team had notified Fedje Vessel Traffic Service (VTS) of entering the area and followed the reported voyage. Sola TS had been loaded with crude oil at the Sture Terminal, and notified Fedje VTS of departure from the terminal. Sola TS exhibited navigation lights. In addition some of the deck lights were turned on to light up the deck for the crew who were securing equipment etc. for the passage.

In advance of the collision, Fedje VTS had not followed the frigate’s passage south through the Hjeltefjord. The crew and pilot on Sola TS had observed HNoMS Helge Ingstad and tried to warn of the danger and prevent a collision. The crew on HNoMS Helge Ingstad did not realise that they were on collision course until it was too late.

At 04:01:15, HNoMS Helge Ingstad collided with the tanker Sola TS. The first point of impact was Sola TS’ starboard anchor and the area just in front of HNoMS Helge Ingstad’s starboard torpedo magazine.

HNoMS Helge Ingstad suffered extensive damage along the starboard side. Seven crew members sustained minor physical injuries. Sola TS received minor damages and none of the crew were injured. Marine gas oil leaked out into the Hjeltefjord. The Institute of Marine Research has ascertained the effect of the oil spill had little impact on the marine environment.

The AIBN’s investigation has shown that the situation in the Hjeltefjord was made possible by a number of operational, technical, organisational and systemic factors:

  • As a consequence of the clearance process, the career ladder for fleet officers in the Navy and the shortage of qualified navigators to man the frigates, officers of the watch had been granted clearance sooner, had a lower level of experience and had less time as officer of the watch than used to be the case. This had also resulted in inexperienced officers of the watch being assigned responsibility for training. Furthermore, several aspects of the bridge service were not adequately described or standardised. The night of the accident, it turned out, among other things, that the bridge team on HNoMS Helge Ingstad did not manage to utilise the team’s human and technical resources to detect, while there was still time, that what they thought was a stationary object giving off the strong lights, in fact was a vessel on collision course. Organisation, leadership and teamwork on the bridge were not expedient during the period leading up to the collision. In combination with the officer of the watch’s limited experience, the training being conducted for two watchstanding functions on the bridge reduced the bridge team’s capacity to address the overall traffic situation. Based on a firmly lodged situational awareness that the ‘object’ was stationary and that the passage was under control, little use was made of the radar and AIS to monitor the fairway.

  • When Sola TS set out on its northbound passage with the forward-pointing deck lights turned on, it was difficult for the frigate’s bridge team to see the tanker’s navigation lights and the flashing of the Aldis lamp, and thereby identify the ‘object’ as a vessel. The shipping company Tsakos Columbia Shipmanagement SA had not established compensatory safety measures with regards to the reduction of the visibility of the navigation lights due to deck lighting. Furthermore, radar plotting and communication on the bridge did not sufficiently ensure the effect of active teamwork to build a common situational awareness. This could have increased the time window for identification and warning of the frigate.

  • The Norwegian Coastal Administration (NCA) had not established human, technical and organisational barriers to ensure adequate traffic monitoring. The functionality of the monitoring system with regards to automatic plotting, warning and alarm functions, was not sufficiently adapted to the execution of the vessel traffic service. Lack of monitoring meant that the VTS operator’s situational awareness and overview of the VTS area were inadequate. Hence, Fedje VTS did not provide the vessels involved with relevant and timely information and did not organise the traffic to ensure the tanker’s safe departure from the Sture Terminal.

  • On the southbound voyage, HNoMS Helge Ingstad sailed with AIS in passive mode. This meant that the frigate could not be immediately identified on the screens at Fedje VTS or Sola TS. None of the parties involved made sufficient use of available technical aids. It was a challenge for maritime safety that the Navy could operate without AIS transmission and without compensatory safety measures within a traffic system where the other players largely used AIS as their primary (and to some extent only) source of information.
Safety recommendation

Safety recommendation MARINE No 2019/05T

On the southbound voyage in the early hours of 8 November 2018, training was being conducted for two watchstanding functions on the bridge of HNoMS Helge Ingstad. The training activity meant that the bridge team’s capacity to address the overall traffic situation was reduced. The Navy lacked competence requirements for instructors and procedures to ensure the functioning of the bridge team while administering training.

The Accident Investigation Board Norway recommends that the Royal Norwegian Navy establish competence requirements and procedures for training activity on the bridge, attending to both the training function and safe navigation.

Safety recommendation MARINE No 2019/06T

On the southbound passage through the Hjeltefjord in the early hours of 8 November 2018, while training activity was being conducted on the bridge of HNoMS Helge Ingstad, the navigator in charge did not pick up on the signals of danger or that the navigator’s own situational awareness was inaccurate. A more experienced navigator would have been better equipped to realise this. As a consequence of the clearance process, the career ladder for fleet officers in the Navy and the shortage of qualified navigators to man the frigates, officers of the watch had been granted clearance sooner, had a lower level of experience and had less time as officer of the watch than used to be the case.

The Accident Investigation Board Norway recommends that the Royal Norwegian Navy consider the career path and the clearance process for officers in the Fleet in relation to the Navy’s manning concept for frigates, with a view to ensuring that bridge teams have a sufficient level of competence and experience.

Safety recommendation MARINE No 2019/07T

On the southbound passage through the Hjeltefjord in the early hours of 8 November 2018, a more coordinated bridge team on HNoMS Helge Ingstad would have been more capable of detecting the tanker sooner. Achieving good bridge resource management (BRM) is particularly challenging in the case of bridge teams whose members are constantly being replaced.

The Accident Investigation Board Norway recommends that the Royal Norwegian Navy establish systematic bridge resource management (BRM) training for the whole bridge team.

Safety recommendation MARINE No 2019/08T

On the southbound passage through the Hjeltefjord in the early hours of 8 November 2018, the tanker was not detected in time to avoid the collision. Organisation, leadership and teamwork on the bridge of HNoMS Helge Ingstad were not expedient. In addition, the governing bridge service documents (the bridge manual) provided insufficient job support with regards to risk assessment and ensuring a safe voyage.

The Accident Investigation Board Norway recommends that the Royal Norwegian Navy review and revise the governing bridge service documents.

Safety recommendation MARINE No 2019/09T

The investigation of the collision in the Hjeltefjord in the early hours of 8 November 2018, has found that the personnel on the bridge on HNoMS Helge Ingstad was not correctly put together with regards to the requirements for vision in current regulations. Medical fitness assessment and follow-up is meant to ensure that everyone who serves in a given position, is medically fit to perform such service safely and effectively.

The Accident Investigation Board Norway recommends that the Royal Norwegian Navy review and improve its system for medical fitness assessment and follow-up with regards to vision.

Safety recommendation MARINE No 2019/10T

On the southbound passage through the Hjeltefjord in the early hours of 8 November 2018, HNoMS Helge Ingstad sailed with AIS in passive mode. This meant that the vessel could not be immediately identified on the screens at Fedje VTS and Sola TS. It was a challenge for maritime safety that the Navy was able to operate without AIS transmission and without compensatory safety measures within a traffic system where the other players largely used AIS as their primary source of information.

The Accident Investigation Board Norway recommends that the Royal Norwegian Navy review the use of AIS and ensure that adequate compensatory measures are put in place when using AIS in passive or encrypted mode.

Safety recommendation MARINE No 2019/11T

If HNoMS Helge Ingstad had set AIS to mode 3 (Warship AIS) for the voyage in the early hours of 8 November 2018, it’s highly likely that the VTS monitoring system would have displayed the AIS information. The investigation has found that the dialogue between the NCA and the Navy about the use of W-AIS in the Fedje VTS area, faded away before guidelines for such use were in place. The AIBN considers use of W-AIS in VTS areas to potentially be a valuable safety barrier in situations where use of AIS mode 1 is not appropriate.

The Accident Investigation Board Norway recommends that the Royal Norwegian Navy, in cooperation with the Norwegian Coastal Administration, resume and formalise their combined effort to develop and implement guidelines for the use of Warship AIS in the Fedje VTS area, as well as in other Norwegian VTS areas as required.

Safety recommendation MARINE No 2019/12T

On the southbound passage through the Hjeltefjord in the early hours of 8 November 2018, HNoMS Helge Ingstad sailed with AIS in passive mode. This meant that the vessel could not be immediately identified on the screens at Fedje VTS or the displays on Sola TS. When operational demands led to a change of practice to more use of AIS in passive mode, the applicable rules in the navigation requirements were set aside.

The Accident Investigation Board Norway recommends that the Royal Norwegian Navy review the operating concept and ensure that safety management and operational needs are compared as management parameters.

Safety recommendation MARINE No 2019/13T

The access to factual information in order to map the sequence of events in the collision in the Hjeltefjord in the early hours of 8 November 2018, has been somewhat limited by the lack of Voyage Data Recorder (VDR) on board HNoMS Helge Ingstad. Had VDR data from HNoMS Helge Ingstad been available, the AIBN would have had access to unique data to document the sequence of events more exactly, and to better understand the situation on board the frigate.

The Accident Investigation Board Norway recommends that the Royal Norwegian Navy install VDR on the Navy’s vessels.

Safety recommendation MARINE No 2019/14T

The investigation of the collision in the Hjeltefjord in the early hours of 8 November 2018, has found that the bridge team on HNoMS Helge Ingstad may have been somewhat affected by fatigue, particularly considering the time of day. In the absence of systematic logging of working hours and hours of rest etc., it has not been possible to further investigate the degree to which the bridge team may have been affected by fatigue. The Ministry of Defence has initiated the process of establishing protective provisions for sea-going personnel in the Navy.

The Accident Investigation Board Norway recommends that the Ministry of Defence introduce, particularly relating to critical functions, a system to give the Navy a systematic overview and positive control of hours of rest. In addition, a requirement for compensatory measures should be put in place when non-compliance with the provided hours of rest in the civilian protective provision.

Safety recommendation MARINE No 2019/15T

When leaving the Sture Terminal in the early hours of 8 November 2018, Sola TS had the forward-pointing deck lights turned on to light up the deck for the crew who were securing equipment etc. for the passage. The deck lights reduced the visibility of both the navigation lights and the flashes from the Aldis lamp. This contributed to the bridge team on HNoMS Helge Ingstad not managing to visually identify Sola TS as a vessel.

The Accident Investigation Board Norway recommends that the shipping company Tsakos Columbia Shipmanagement S.A. establish safety measures for the use of deck lights on vessels, which ensures that the deck lights do not reduce the visibility of the navigation lights.

Safety recommendation MARINE No 2019/16T

During the voyage from the Sture Terminal in the early hours of 8 November 2018, neither HNoMS Helge Ingstad nor any other vessels were plotted on the radar on Sola TS. Furthermore, there was little communication between the bridge team and the pilot about the voyage and the general traffic situation in the fairway. This meant that the effect of active teamwork to build a common situational awareness was not sufficiently ensured.

The Accident Investigation Board Norway recommends that the shipping company Tsakos Columbia Shipmanagement S.A. review and improve its practice relating to cooperation on the bridge and safe navigation on vessels under pilotage.

Safety recommendation MARINE No 2019/17T

The investigation of the collision in the Hjeltefjord in the early hours of 8 November 2018, has found that Sola TS’ deck lights reduced the visibility of both the navigation lights and the flashes from the Aldis lamp. This contributed to the bridge team on HNoMS Helge Ingstad not managing to visually identify Sola TS as a vessel. It is a known fact and normal practice that the tankers on their way to the terminal need to start preparing for mooring and loading, and that the vessels on their way out prepare for the ocean-going voyage.

The Accident Investigation Board Norway recommends that the Norwegian Maritime Authority address the industry in general with regards to the use of deck lighting which could reduce the visibility of the vessel’s navigation lights.

Safety recommendation MARINE No 2019/18T

In the early hours of 8 November 2018, the VTS centre did not monitor the southbound voyage of HNoMS Helge Ingstad through the Hjeltefjord. The NCA had not established human, technical and organisational barriers to ensure adequate traffic monitoring. The functionality of the monitoring system with regards to automatic plotting, warning and alarm functions, was not adapted to the execution of the vessel traffic service.

The Accident Investigation Board Norway recommends that the Norwegian Coastal Administration review and improve how traffic monitoring is conducted, with regards to manning, tasks and technical aids.

Safety recommendation MARINE No 2019/19T

In the early hours of 8 November 2018, Fedje VTS did not adequately inform other traffic in the area of Sola TS leaving the Sture Terminal. An efficient and correct information service is an important contribution to situational awareness for all vessels when tankers operate within the VTS area. Due to the lack of traffic information the frigate’s bridge team missed an opportunity to register that a tanker was leaving the Sture terminal.

The Accident Investigation Board Norway recommends that the Norwegian Coastal Administration review and improve its procedures and practice for traffic information.

Location
Outside the Sture Terminal in the Hjeltefjord, Norway
Occurrence date
08.11.2018
Accident category
Collision
Area
Norwegian Territorial Waters
IMO number
- / 9724350
Name of vessel
HNoMS Helge Ingstad/Sola TS
Accident type
Pollution/environmental damage, Capsize, Collision
Vessel type
Misc. Ship/ Tanker
Register
The Norwegian Ship Register/ Other Flag State
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