This is very interesting:
Thats the preliminary translation of the inquiry findings , 208 pages long
1.3 Key conclusions
A selection of key conclusions of the report is here presented. The order does not say anything about their importance in relation to the accident and the Commission’s terms of reference.
Key conclusions are:
• The vessel was built and equipped as an all-round vessel AHSV (Anchor Handling Supply Vessel). Uniting these functions poses special challenges.
In addition to bollard pull, anchor-handling demands thruster capacity,
powerful winches, big drums and equipment for handling chain. Supply and
cargo operations demand the biggest possible, and also flexible, cargo
capacities both on deck and in tanks. The “Bourbon Dolphin” was a
relatively small and compact vessel, in which all these requirements were to
• The company had no previous experience with the A 102 design and ought
therefore to have undertaken more critical assessments of the vessel’s
characteristics, equipment and not least operational limitations, both during
her construction and during her subsequent operations under various
conditions. The company did not pick up on the fact that the vessel had
experienced an unexpected stability-critical incident about two months after
• The vessel’s stability-related challenges were not clearly communicated from
shipyard to company and onwards to those who were to operate the vessel.
• Under given load conditions the vessel did not have sufficient stability to
handle lateral forces. The winch’s pulling-power was over-dimensioned in
relation to what the vessel could in reality withstand as regards stability.
• The anchor-handling conditions prepared by the shipyard were not realistic.
Nor did the Norwegian Maritime Directorate’s regulatory system make any
requirement that these be approved.
• The ISM Code demands procedures for the key operations that the vessel is
to perform, Despite the fact that anchor-handling was the vessel’s main
function, there was no vessel-specific anchor-handling procedure for the
• The company did not follow the ISM code’s requirement that all risk be
• The company did not make sufficient requirements for the crew’s
qualifications for demanding operations. The crew’s lack of experience was
not compensated for by the addition of experienced personnel.
• The master was given 1½ hours to familiarise himself with the crew and
vessel and the ongoing operation. In its safety management system the
company has a requirement that new crews shall be familiarised with
(inducted into) the vessel before they can take up their duties on board. In
practice the master familiarises himself by overlapping with another master
who knows the vessel, before he himself is given the command.
• Neither the company nor the operator ensured that sufficient time was made available for hand-over in the crew change.
• The vessel was marketed with continuous bollard pull of 180 tonnes. During
an anchor-handling operation, in practice thrusters are always used for
manoeuvring and dynamic positioning. The real bollard pull is then
materially reduced. The company did not itself investigate whether the vessel
was suited to the operation, but left this to the master.
• The company did not see to the acquisition of information about the content and scope of the assignment the “Bourbon Dolphin” was set to carry out. The company did not itself do any review of the Rig Move Procedure (RMP) with a view to risk exposure for crew and vessel. The company was thus not in a position to offer guidance.
• The Norwegian classification society Det norske Veritas (DNV) and the
Norwegian Maritime Directorate were unable to detect the failures in the
company’s systems though their audits.
• In specifying the vessel, the operator did not take account of the fact that the real bollard pull would be materially reduced through use of thrusters. In
practice the “Bourbon Dolphin” was unsuited to dealing with the great forces
to which she was exposed.
• The mooring system and the deployment method chosen were demanding to
handle and vulnerable in relation to environmental forces.
• Planning of the RMP was incomplete. The procedure lacked fundamental and
concrete risk assessments. Weather criteria were not defined and the forces
were calculated for better weather conditions than they chose to operate in.
Defined safety barriers were lacking. It was left to the discretion of the rig
and the vessels whether operations should start or be suspended.
• In advance of the operation no start-up meeting with all involved parties was held. The vessels did not receive sufficient information about what could be expected of them, and the master misunderstood the vessel’s role.
• The procedure demanded the use of two vessels that had to operate at close quarters in different phases during the recovery and deployment of anchors. The increased risk exposure of the vessels was not reflected in the procedure.
• The procedure lacked provisions for alternative measures (contingency
planning), for example in uncontrollable drifting from the run-out line. Nor
were there guidelines for when and in what way such alternative measures
should be implemented and what if any risk these would involve.
• The deployment of anchor no. 2 was commenced without the considerable
drifting during the deployment of the diagonal anchor no. 6 had been evaluated.
• Human error on the part of the rig and the vessels during the performance of the operation.
• Communication and coordination between the rig and the vessel was
defective during the last phase of the operation.
• Lack of involvement on the part of the rig when the “Bourbon Dolphin”
• The roll reduction tank was most probably in use at the time of the accident.
• The inner starboard towing pin had been depressed and the chain was lying
against the outer starboard towing pin. The chain thereby acquired a changed
angle of attack.