GovWire

Accident Investigation Report 6/2024

Summary

At 0436 on 25 October 2022, the Malta registered oil and chemical tanker Ali Ka made contact with the westernmost section of Oikos Jetty 2 at Canvey Island on the River Thames, England. The vessel was departing the berth under compulsory Port of London Authority (PLA) pilotage and without a tug in attendance. The impact caused minor damage to the ship but severe damage to the jetty. Ali Ka grounded close to the pier. Two tugs were deployed and Ali Ka was successfully recovered to Oikos Jetty 1. No one was injured and there was no pollution. It took eleven months for the Oikos facility to return to pre-accident capacities.

The Oikos fuel storage facility was part of the national infrastructure for the import and distribution of distillate fuel in the UK. It was regulated by the Health and Safety Executive under the Control of Major Accident Hazards Regulations 2015 (COMAH).

Safety Issues

• Control of Ali Ka was lost because the pilots plan missed key information, was compromised by incoherencies in documentation, there was no tug used, and the pilot was highly likely to have been severely fatigued

• The master/pilot exchange was ineffective and did not result in the bridge team fully participating in an appropriately modified and agreed plan

• Several interventions were made to change the plan, but none were effective, and no one dealt well with the challenges presented

• Previous accidents were not recognised as warnings and risk controls were not reappraised in time to inform the approaches employed for Ali Ka, for example in tug provision

• The PLA and Oikos Storage Limited risk management processes did not combine to mitigate the risk of vessel collision with shore infrastructure at a COMAH site

Recommendations

MAIB has made eight safety recommendations, including:

The PLA was recommended to

• Conduct collaborative risk assessments of all COMAH and high-risk berths in the statutory harbour authority area, in particular by reconsidering tug use over a range of environmental conditions

• Provide guidance to their pilots and operational staff on dealing with the recognition, escalation, and safe resolution of challenges

• Review the risks to safe pilotage from pilot fatigue, informed by an independent, specialist review of current working practices and, as necessary, implement focused mitigations in a comprehensive fatigue risk management system

Transka Tankers was recommended to

• Review and revise its Bridge Resource Management training to include agreeing and assigning roles and responsibilities, support to embarked pilots, diligent exercise of the master/pilot exchange, and challenge and response procedures specific to working with an embarked pilot

• Review and revise the policy for the accurate setting of safety contours in its Electronic Chart Display and Information System (ECDIS) to best support pilotage and the appreciation of risk during manoeuvring to and from the berth

Oikos Storage Limited was recommended to

• Conduct collaborative risk assessments of its berths and give specific consideration to assurance mechanisms where the safety of Oikos infrastructure is dependent on mitigations delivered by external organisations. Particular regard was to be given to pilotage and tug use over a range of environmental conditions

The International Chamber of Shipping was recommended to

• Include bridge team roles and responsibilities to be agreed during the master/pilot exchange in the next iteration of the Bridge Procedures Guide

Related publications

The final report references the following MAIB publications:

Sichem Melbourne, (MAIB Report 18/2008)

Vallermosa, (MAIB Report 23/2009)

CMA CGM Platon (MAIB Report 26/2011)

Amber (MAIB Report 22/2013)