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



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.



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



ISSN 0333-2306ISBN 978-82-583-0965-6

07 Gruppen AS, Oslo



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



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)



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



6 NOU 2 2: ?

Eierbegrensning og eierkontroll i finansinstitusjoner



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



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



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



2



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



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



15NOU2008:8


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



16 NOU2008:8


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.



17NOU2008:8


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)



18 NOU2008:8


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



30 NOU2008:8


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



31NOU2008:8


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



34 NOU2008:8


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



35NOU2008:8


Asatechnicalreferencefor themooringsys- Inaddition,Clevrondemandedthat themoor-temDepartmentofEnergy4thEditionGuidance ing system satisfied the POSMOOR require-Notes32.2,MODUCodepart4.11.8andinternal ments. Transocean specifications was chosen by Transocean.



36 NOU2008:8


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



38 NOU2008:8


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



47NOU2008:8


Figure 5.2 General arrangement



48 NOU2008:8


Figure 5.3 Tank plan



49NOU2008:8


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



53NOU2008:8


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



55NOU2008:8


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




68 NOU2008:8



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.



69NOU2008:8


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



71NOU2008:8


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



73NOU2008:8


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



75NOU 2008: 8

The loss of the “Bourbon Dolphin” on 12 April 2007 Chapter 7

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”



77NOU2008:8


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”



78 NOU2008:8


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”



79NOU2008:8


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



87NOU2008:8


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.



NOU2008:8 97 Thelossofthe“BourbonDolphin”on12April2007 Chapter9

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




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.




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


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




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-



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


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



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




Figure 9.16 Correcting and heeling arms for load condition 3.2 after towing-pin is depressed, 60% angle of


“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.




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.




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




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




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



116 NOU2008:8


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.




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.




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



120 NOU2008:8


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.



122 NOU2008:8


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




“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



124 NOU2008:8


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.




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.




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




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.




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




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




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




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




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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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.



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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P:O: Box 84 Blindern0314 Oslo, NorwayE-mail: [email protected] Telephone: +47 22 18 81 00 Telefax: +47 22 18 81 01

This publication is also availableat the following website: www.regjeringen.no

the loss of the bourbon dolphin 12.4.2007

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