Delrapport 2 om kollisjonen mellom fregatten KNM Helge Ingstad og tankbåten Sola TS utenfor Stureterminalen i Hjeltefjorden, Hordaland, 8. november 2018

In the early hours of Thursday 8 November 2018, the frigate HNoMS 'Helge Ingstad’ and the tanker ‘Sola TS’ collided outside the Sture Terminal in the Hjeltefjord. The frigate subsequently grounded and sank. The investigation has shown that the crew on board the frigate experienced that they lacked a functional decision support tool (stability calculator) throughout the sequence of events. The carpet plot that was available on board was not very suitable to assessing the frigate’s survivability when damaged.

The Norwegian Safety Investigation Authority recommends that the Royal Norwegian Navy ensure that the frigate crews have a decision support tool available on board so as to be able to assess the ship’s damage stability and survivability in any situation of damage.

In the early hours of Thursday 8 November 2018, the frigate HNoMS 'Helge Ingstad’ and the tanker ‘Sola TS’ collided outside the Sture Terminal in the Hjeltefjord. The frigate subsequently grounded and sank. The investigation has shown that there was little knowledge about stability on board the frigate and that only two crew members had in-depth knowledge of intact and damage stability. As a result of this and the experienced lack of a functional decision support tool, the crew lacked a sufficient basis for assessing how critical the damage was.

The Norwegian Safety Investigation Authority recommends that the Royal Norwegian Navy strengthen its competence in damage stability and determine what members of the frigate crews shall have key roles relating to intact and damage stability.

In the early hours of Thursday 8 November 2018, the frigate HNoMS 'Helge Ingstad’ and the tanker ‘Sola TS’ collided outside the Sture Terminal in the Hjeltefjord. The frigate subsequently grounded and sank. The investigation has shown that the frigate was not in the ordered equipment protection level during passage and was not shut down before she was evacuated. The crew lacked competence relating to damage stability and the importance of the shutdown state for the frigate’s survivability when damaged. As a result, watertight integrity was not adequately maintained, so that the frigate eventually sank.

The Norwegian Safety Investigation Authority recommends that the Royal Norwegian Navy strengthen the frigate crews’ awareness and competence relating to the importance of shutting down the vessel to maintain her watertight integrity and survivability when damaged.

In the early hours of Thursday 8 November 2018, the frigate HNoMS 'Helge Ingstad’ and the tanker ‘Sola TS’ collided outside the Sture Terminal in the Hjeltefjord. The frigate subsequently grounded and sank. The investigation has shown that challenges associated with cables and hoses for portable bilge pumps passing through doors and hatches between the frigate’s watertight decks and compartments formed part of the background to why the frigate was not shut down. The investigation has also shown that it was difficult to gain an overview of the amount of water entering the frigate and to assess this in relation to the available pumping capacity.

The Norwegian Safety Investigation Authority recommends that the Royal Norwegian Navy, in cooperation with the Norwegian Defence Materiel Agency, define the scenarios in which portable bilge pumps can be expected to have an effect, and implement measures to maintain watertight integrity while also ensuring effective damage control.

In the early hours of Thursday 8 November 2018, the frigate HNoMS 'Helge Ingstad’ and the tanker ‘Sola TS’ collided outside the Sture Terminal in the Hjeltefjord. The frigate subsequently grounded and sank. The investigation has shown that, as part of a watertight compartment, the Q-deck was very important for the frigate’s survivability, particularly in case of damage to the afterbody. The deck was designed with a large number of closeable openings and meant to serve as a work deck in port and under certain combat operations. A design with several hatches, whereas, some should be kept open during operation, could be in conflict with the requirement to watertight integrity.

The Norwegian Safety Investigation Authority recommends that the Norwegian Defence Materiel Agency consider how relevant rules and regulations can be developed to better meet requirements for watertight integrity in combination with operational requirements.

In the early hours of Thursday 8 November 2018, the frigate HNoMS 'Helge Ingstad’ and the tanker ‘Sola TS’ collided outside the Sture Terminal in the Hjeltefjord. The frigate subsequently grounded and sank. The Q-deck was designed with a large number of closeable openings. This is a vulnerable design where verification of the watertightness is a necessity for having control of the seaworthiness of the frigate. The investigation has shown that standard test methods for verification of watertight integrity of hatches and doors did not reveal leak points on Q-deck.

The Norwegian Safety Investigation Authority recommends that the Norwegian Defence Materiel Agency review established routines and methods for verification of watertightness to ensure control of the watertight integrity of the vessel.

In the early hours of Thursday 8 November 2018, the frigate HNoMS 'Helge Ingstad’ and the tanker ‘Sola TS’ collided outside the Sture Terminal in the Hjeltefjord. The frigate subsequently grounded and sank. The investigation has shown that the design-phase assumption that the Q-deck would be watertight was not followed up and implemented in the operating phase. Adequate systems had not been put into place to ensure that this knowledge was conveyed to those who would operate the vessel when the frigates were commissioned.

The Norwegian Safety Investigation Authority recommends that the Norwegian Defence Materiel Agency, in cooperation with the Royal Norwegian Navy, review all design assumptions and take steps as necessary to ensure that these assumptions hold true during operation.

In the early hours of Thursday 8 November 2018, the frigate HNoMS 'Helge Ingstad’ and the tanker ‘Sola TS’ collided outside the Sture Terminal in the Hjeltefjord. The frigate subsequently grounded and sank. The investigation has shown that the spring-loaded overpressure valves on 2 deck in section 13 compromised watertight integrity.

The Norwegian Safety Investigation Authority recommends that the Norwegian Defence Materiel Agency, in cooperation with the Royal Norwegian Navy, implements necessary measures to ensure watertight integrity of section 13.

In the early hours of Thursday 8 November 2018, the frigate HNoMS 'Helge Ingstad’ and the tanker ‘Sola TS’ collided outside the Sture Terminal in the Hjeltefjord. The frigate subsequently grounded and sank. The investigation has shown that pumping never became effective on board the frigate. The crew lacked thorough system competence and there had been few practical exercises and little training in this area.

The Norwegian Safety Investigation Authority recommends that the Royal Norwegian Navy ensure that the frigate crews are competent enough and have sufficient training to operate the bilge system in any relevant situation.

In the early hours of Thursday 8 November 2018, the frigate HNoMS 'Helge Ingstad’ and the tanker ‘Sola TS’ collided outside the Sture Terminal in the Hjeltefjord. The frigate subsequently grounded and sank. The investigation has shown that there was lack of segregation between the frigate’s main bilge system and the bilge sullage system for day-to-day removal of bilge water and oily water. The Norwegian Defence Materiel Agency had approved the design without understanding the ensuing risk. This contributed, amongst others, to there being little training and exercises in use of the system and to its vulnerabilities not being identified.

The Norwegian Safety Investigation Authority recommends that the Norwegian Defence Materiel Agency, in cooperation with the Royal Norwegian Navy, address this nonconformity in the bilge system in compliance with applicable regulations.

In the early hours of Thursday 8 November 2018, the frigate HNoMS 'Helge Ingstad’ and the tanker ‘Sola TS’ collided outside the Sture Terminal in the Hjeltefjord. The frigate subsequently grounded and sank. The investigation has shown that several of the valves in the bilge system, which is by the Norwegian Armed Forces defined as a safety critical system, were inaccessible to the frigate crew throughout the sequence of events. Several valves were located under bolted-down floor grates, which made it challenging to operate them manually if remote control failed. It was also not possible to operate the motorised valves manually from decks above 4 deck if remote control from HQ1 or from the local panel on deck 2 should fail.

The Norwegian Safety Investigation Authority recommends that the Norwegian Defence Materiel Agency, in cooperation with the Royal Norwegian Navy, perform a risk assessment to ensure sufficient access for manual operation of motorised valves in the bilge system for the Navy’s vessels.

In the early hours of Thursday 8 November 2018, the frigate HNoMS 'Helge Ingstad’ and the tanker ‘Sola TS’ collided outside the Sture Terminal in the Hjeltefjord. The frigate subsequently grounded and sank. The investigation has shown that several valves in the frigate’s bilge system did not seal, which considerably reduced the system’s pumping capacity. The technical circumstances made it almost impossible for the crew to realise this during the incident. The investigation also showed that regular verification, correction and/or calibration of the system were not carried out.

The Norwegian Safety Investigation Authority recommends that the Royal Norwegian Navy, in cooperation with the Norwegian Defence Materiel Agency, take steps to ensure that the valves in the bilge system seal in closed position so that the expected pumping capacity can be achieved.

In the early hours of Thursday 8 November 2018, the frigate HNoMS 'Helge Ingstad’ and the tanker ‘Sola TS’ collided outside the Sture Terminal in the Hjeltefjord. The frigate subsequently grounded and sank. The investigation has shown that the total pumping capacity on a sister ship of the same design as HNoMS 'Helge Ingstad' was not in accordance with the specification established by the Norwegian Defence Materiel Agency for the vessel class. The bilge system had been defined as a safety-critical system, but it did not deliver the expected capacity.

The Norwegian Safety Investigation Authority recommends that the Norwegian Defence Materiel Agency, in cooperation with the Royal Norwegian Navy, assess the need for bilge pumping capacity and identity and take necessary steps on the basis of such an assessment.

In the early hours of Thursday 8 November 2018, the frigate HNoMS 'Helge Ingstad’ and the tanker ‘Sola TS’ collided outside the Sture Terminal in the Hjeltefjord. The frigate subsequently grounded and sank. The investigation has shown that the Norwegian Defence Materiel Agency was unable to explain the background for their required bilge capacity, and how this was covered in the applicable regulatory requirement. The regulations in their present form do not take sufficient account of system complexities and obstructions. Ships may therefore sail with a system that neither delivers the expected capacity nor meets actual needs that arise in a damage control situation.

The Norwegian Safety Investigation Authority recommends that the Norwegian Defence Materiel Agency, in cooperation with the International Naval Safety Association, consider the need to impose additional requirements to the bilge system those in applicable regulations with a view to ensuring that capacity needs are identified and met, and system complexity is taken into account during design and in requirements to test the bilge systems.

In the early hours of Thursday 8 November 2018, the frigate HNoMS 'Helge Ingstad’ and the tanker ‘Sola TS’ collided outside the Sture Terminal in the Hjeltefjord. The frigate subsequently grounded and sank. The investigation has shown that the Navy’s crisis management team lacked sufficient competence relating to stability. The Norwegian Defence Materiel Agency had competence in stability, but it was late in arriving and coordination with the crisis management team was poor. Lack of coordination between the Navy and the Norwegian Defence Materiel Agency’s contingency plans was the reason why decision support was not arranged or provided at an early enough time after the frigate ran aground. The officers in command at the scene therefore had to make decisions based on their own knowledge and limited information available.

The Norwegian Safety Investigation Authority recommends that the Royal Norwegian Navy, in cooperation with the Norwegian Defence Materiel Agency, review contingency plans, assess how crisis management should be organised and what competence is needed to provide early assistance and reduce the risk of loss of personnel or vessel in a critical situation.

In the early hours of Thursday 8 November 2018, the frigate HNoMS 'Helge Ingstad’ and the tanker ‘Sola TS’ collided outside the Sture Terminal in the Hjeltefjord. The frigate subsequently grounded and sank. The investigation has shown that the Norwegian Armed Forces have not established a systemic approach for learning from undesirable incidents and improving the safety management system in an overall and consistent manner. A need for learning has also been clearly identified in previous accident reports, and measures have been proposed that have not been adequately followed up or implemented. Learning is largely a local responsibility. There is thus an absence of learning between departments or across the rest of the organisation.

The Norwegian Safety Investigation Authority recommends that the Norwegian Armed Forces establish mechanisms for organisational learning from undesirable incidents and accidents.

In the early hours of Thursday 8 November 2018, the frigate HNoMS 'Helge Ingstad’ and the tanker ‘Sola TS’ collided outside the Sture Terminal in the Hjeltefjord. The frigate subsequently grounded and sank. The investigation has shown that neither the Navy nor the Norwegian Defence Materiel Agency was sufficiently informed about the potential consequences of known technical nonconformities for the safe operation of the frigates. The Navy has thus operated the frigates without being aware of the total risk under which they were sailing as a result of the unaddressed nonconformities. Several of the nonconformities were of direct consequence for the sequence of events.

The Norwegian Safety Investigation Authority recommends that the Royal Norwegian Navy, in cooperation with the Norwegian Defence Material Agency, take steps to ensure that the Navy gets an overview of risks associated with all nonconformities of consequence for safe operation.

In the early hours of Thursday 8 November 2018, the frigate HNoMS 'Helge Ingstad’ and the tanker ‘Sola TS’ collided outside the Sture Terminal in the Hjeltefjord. The frigate subsequently grounded and sank. The investigation has shown that there have been few or no system courses and little or no simulator training in the Navy for the purpose of acquiring more in-depth competence in several technical systems. The investigation has also shown that the sailing programme and operative ambition level have made it challenging to set aside enough time for courses and simulator training. As a result, the crew did not have the requisites to be able to handle the scenario they found themselves in on the morning of the accident.

The Norwegian Safety Investigation Authority recommends that the Royal Norwegian Navy, in cooperation with the Norwegian Defence Materiel Agency, take steps to ensure that the frigate crews have the requisites required to operate all technical systems in all relevant situations.

In the early hours of Thursday 8 November 2018, the frigate HNoMS 'Helge Ingstad’ and the tanker ‘Sola TS’ collided outside the Sture Terminal in the Hjeltefjord. The frigate subsequently grounded and sank. The investigation has shown that important elements were missing in the crew’s sea training. Not enough time and resources were devoted to realistic exercises in mastering complex damage control situations. As a result, the crew did not have the competence required to manage a more complex and time-critical damage control situation.

The Norwegian Safety Investigation Authority recommends that the Royal Norwegian Navy evaluate and implement measures in its own training and exercise programme to ensure that the frigate crews have the competence required to handle complex damage control scenarios.

In the early hours of Thursday 8 November 2018, the frigate HNoMS 'Helge Ingstad’ and the tanker ‘Sola TS’ collided outside the Sture Terminal in the Hjeltefjord. The frigate subsequently grounded and sank. The investigation has shown that the frigates are not manned in accordance with important requirements for the lean manning concept. It has also not been demonstrated how the basis for lean manning of the frigates was to be addressed through clear requirements for competence, experience and personnel rotation. This constitutes a vulnerability in the safe operation of these vessels and compromises the Fleet’s ability to produce combat-ready units.

The Norwegian Safety Investigation Authority recommends that the Royal Norwegian Navy review and conduct a risk assessment of the manning concept for the frigates and introduce measures as necessary to clarify the requirements for the concept and how they are to be followed up.

In the early hours of Thursday 8 November 2018, the frigate HNoMS 'Helge Ingstad’ and the tanker ‘Sola TS’ collided outside the Sture Terminal in the Hjeltefjord. The frigate subsequently grounded and sank. The investigation has shown that it has not been possible to retrieve valid technical documentation of certain systems on board the frigate. Safe operation of the frigates is not possible without good configuration management and updated technical documentation.

The Norwegian Safety Investigation Authority recommends that the Norwegian Defence Materiel Agency, in cooperation with the Royal Norwegian Navy, review and update the technical documentation for the Nansen-class frigates, so as to achieve safe operation of the frigates.

In the early hours of Thursday 8 November 2018, the frigate HNoMS 'Helge Ingstad’ and the tanker ‘Sola TS’ collided outside the Sture Terminal in the Hjeltefjord.  The frigate subsequently grounded and sank. The investigation has shown that it has not been possible to locate valid technical documentation for some of the systems on board the frigate. Safe operation of the frigates is not possible without good configuration management and updated technical documentation.

The Norwegian Safety Investigation Authority recommends that the Norwegian Armed Forces Materiel Safety Authority conduct supervisory activities of the Royal Norwegian Navy and the Norwegian Defence Materiel Agency with a view to achieving safe operation of the frigates by ensuring long-term good configuration management and updated technical documentation.

In the early hours of Thursday 8 November 2018, the frigate HNoMS 'Helge Ingstad’ and the tanker ‘Sola TS’ collided outside the Sture Terminal in the Hjeltefjord. The frigate subsequently grounded and sank. The investigation has shown that, over a period of several years before the accident, the frigate crews have notified of manuals not being updated. It was also not clear to the crews who was to follow up and actually update the manuals. This caused the ship crews to implement their own solutions, local routines and procedures. This had negative consequences for both loyalty to procedures and the quality of the manuals, thereby lowering the level of safety in the Navy.

The Norwegian Safety Investigation Authority recommends that the Royal Norwegian Navy initiate measures to update and implement the frigate manuals.

In the early hours of Thursday 8 November 2018, the frigate HNoMS 'Helge Ingstad’ and the tanker ‘Sola TS’ collided outside the Sture Terminal in the Hjeltefjord. The frigate subsequently grounded and sank. The investigation has shown that, as a result of the introduction of a standardised integrated enterprise resource planning (ERP) system for the Norwegian Armed Forces as a whole, the Navy, as the owner with operational responsibility, was obliged to use processes, technology and to some extent also forms of organisation that were sub-optimal for supporting operations. This has had consequences for the safety of naval operations in certain areas.

The Norwegian Safety Investigation Authority recommends that the Norwegian Armed Forces, in cooperation with the Norwegian Defence Materiel Agency, review the Royal Norwegian Navy’s need for system support and take steps to ensure safe ship operation.

In the early hours of Thursday 8 November 2018, the frigate HNoMS 'Helge Ingstad’ and the tanker ‘Sola TS’ collided outside the Sture Terminal in the Hjeltefjord. The frigate subsequently grounded and sank. The investigation has shown that, while the Ship Safety and Security Act entered into force on 1 July 2007, there are still no overall and binding regulations for the defence sector. Incomplete regulations and an unclear framework go some of the way towards explaining why safe ship operation cannot be properly addressed.

The Norwegian Safety Investigation Authority recommends that the Norwegian Ministry of Defence, as the authority with overriding responsibility for ship safety in the defence sector, take steps to clarify the regulatory framework for the purpose of ensuring ship safety.

In the early hours of Thursday 8 November 2018, the frigate HNoMS 'Helge Ingstad’ and the tanker ‘Sola TS’ collided outside the Sture Terminal in the Hjeltefjord. The frigate subsequently grounded and sank. The investigation has shown that the scheme for supervision of naval activities in the defence sector appears to be fragmented and unclear. It does not adequately fulfil the mission of an overall, independent supervisory scheme. The Norwegian Safety Investigation Authority considers this to be unfortunate and that it has possibly had an impact on the safety of naval operations in the defence sector.

The Norwegian Safety Investigation Authority recommends that the Norwegian Ministry of Defence take steps to ensure an overall, independent supervisory function for naval activities in the defence sector.

In the early hours of Thursday 8 November 2018, the frigate HNoMS 'Helge Ingstad’ and the tanker ‘Sola TS’ collided outside the Sture Terminal in the Hjeltefjord. The frigate subsequently grounded and sank. The investigation has shown that the Ministry of Defence has not adequately defined the authorities' roles, and it can be challenging for subordinate agencies to maintain sufficient independence, given the lack of a defined naval administration. The Norwegian Defence Materiel Agency plays a dual role in that it is both responsible for requirements and regulations relating to the materiel and for ensuring compliance with technical safety requirements. This blurs the boundaries, reduces independence and can lead to situations that have negative consequences for the operation of the frigates.

The Norwegian Safety Investigation Authority recommends that the Norwegian Ministry of Defence take steps to ensure that responsibility for requirements and regulations is independent of responsibility for ensuring technical safety under the Ship Safety and Security Act.

In the early hours of Thursday 8 November 2018, the frigate HNoMS 'Helge Ingstad’ and the tanker ‘Sola TS’ collided outside the Sture Terminal in the Hjeltefjord. The frigate subsequently grounded and sank. The investigation has shown that there was an imbalance between tasks and resources relating to the technical operation of the frigates. This had led to a gradual and subtle shift from what is considered good safety management to what has turned into an unstable situation.

The Norwegian Safety Investigation Authority recommends that the Norwegian Defence Materiel Agency, in cooperation with the Royal Norwegian Navy, put in place measures in its own organisation to ensure correct prioritisation with respect to balancing tasks and resources relating to the technical operation of the frigates.