Incident investigations, reports and data

Summary of navigational incidents in the Port of London

An Integral part of the port's Marine Safety Management System involves the investigation of all navigational incidents that are reported to the Harbour Master.

Following an initial assessment, all Navigational Incidents (those affecting or having the potential to impact upon navigational safety) are investigated further, from both a regulatory and safety perspective. Details of the incident, the investigation and outcomes are recorded in an incident database.

Serious Incidents which have been investigated by the Harbour Master are summarised below:

Date

29/03/2021

Incident description

On the 29th March 2021 A container vessel was approaching the berth ready to commence a swing, preparing to berth port side to alongside the terminal when the vessel continued on a south west trajectory and went aground on the opposing side of the channel. The vessel was able to re-float back into the navigational channel with the assistance of tugs and berth safely. No damage, pollution or injuries were caused.

Actions

Contributing factors

There are a number of factors which contributed towards the incident. In summary these were determined to include:

• The lack of a passage plan;
• Vessels speed which caused distraction to the Pilot;
• Lack of monitoring vessels position;
• Inappropriate use of vessel engines, rudder and positioning of tugs;
• Lack of corrective measures when the swing did not go to plan;
• Bridge team management was not effective.

All these factors contributed to the vessel coming to ground on the south side of the navigational channel, when there were no other mechanical or environmental reasons to affect the vessel.

Recommendations on the PLA

Pilot to undertake time in simulator followed by a practical trip with similar vessel characteristics with a senior pilot to enhance learning experience. Pilotage Manager to reissue updated version of OPL/2008/06 and re-word and reissue Operational letter OPL/2008/06 making clear the passage plan process during COVID restrictions.

Harbour Masters to Review best practice and processes for swinging large vessels and are recommended to commence periodical audits of pilot passage plans of all classes to determine if fit for purpose. They are also recommended to develop procedures to include initial actions post serious incident. A copy of the investigation report should be circulated to all Pilots.

Recommendations for tug operator

Superintendent to ensure good positive communication is established & maintained between the Tug Master and Pilot to include confirmation of the securing positions & at all times during towage operations.

Actions taken by the VESSEL

Onboard training to be conducted by Master for all bridge team members including lookout/helmsman.

Training on “Roles/Responsibility of Bridge Team During Pilotage & Master/Pilot Relationship” to be conducted for all deck officers including Master.

DPA to Re-iterate to fleet vessels the need to conduct detailed Master/Pilot Information Exchanges.

DPA to share Incident report with entire fleet vessels for the lessons learnt.

Date

07/07/2019

Incident description

Vessel made contact with number 2 arch of Westminster Bridge, and was subsequently stuck under the bridge.

Actions

Vessel Operator to issue an Operations Memorandum to all crew members as a reminder of all engineering checks which are required, in addition to further educational discussions with the Master.

Date

17/06/2019

Incident description

Crew member injured arm whilst letting go aft spring during letting go operation. Paramedics attended and casualty (Ch. Mate) taken to hospital.

Actions

Note placed in POLARIS asking for the Harbour Master to be informed prior to the next call of the vessel following which the harbour service launch will visit the vessel and inspect it's mooring lines and give educational advice regarding the use of the ship's mooring lines as tow lines.

MAIB have been informed and followed up themselves receiving no further information to that provided by the PLA.

Date

06/06/2019   

Incident description

Fatal man overboard from a recreational angling boat.

Actions

Assistant Harbour Master (Recreational) provided radar recordings and a statement to Kent Police to assist their investigation and report to the Coroner.

PLA to await the findings of the Coroner's Inquest and review to determine any appropriate actions.

Date

04/05/2019

Incident description

On the 4th May 2019 a Pilot tripped on the bridge of a vessel injuring arm resulting in Lost Time Accident.

Actions

PLA are to:

Remind ALL Pilots of the importance to report incidents in a timely manner.

PLA2

Circulate report to all pilots.

F1

Remind Masters for the need for a Good Bridge familiarisation briefing when an new or unfamiliar Pilot is on the Bridge.

F2

Review the highlighting of the raised platform to make more visible. 

Date

22/04/2019

Incident description

Man overboard in an annual canoe race, resulting in a fatality.

Actions

The report recommends that the event organisers conduct a full review of the event risk assessment. This risk assessment is to identify all navigational hazards on the tidal Thames. All hazards are to be assessed and the appropriate level of mitigation is to be put in place before the next event. Further, a comprehensive communications plan to be submitted.

The Harbour Master's Department has taken action with the support of British Canoeing. A Safety Alert was published describing that serious incidents which have occurred in 2019 on the Thames Tideway resulting in paddlers being swept under industrial works barges on the Tideway.

The lessons regarding communications, risk assessment and fatigue are to be shared for all future events as appropriate.

Date

18/01/2019    

Incident description

A Passenger rib with 8 passengers on board was navigating out bound on a charter to North Greenwich Pier.  The Rib was navigating at speed and passed inside the Upper Outer Wing Buoy at which point the Master reduced speed to 26 knots before making contact with the Lower Outer Wing Buoy.  The rib was launched into the air and on landing a number of passenger were knocked out of their seats, but remained on the vessel.  The Master and Deckhand both made contact with the console screen causing facial injuries.

The incident was investigated by the MAIB and MCA Enforcement.  The cause of the incident was a failure to maintain a proper lookout, but further issues were identified with the company’s SMS and Passage Planning.

Actions

The company are to:

1. Revise training including competencies required to keep an effective look out through the Type Rating for the Master and crew

2. Navigational Risk Assessment, SMS and Passage Plan to be updated to address high risk areas and identify hazards to navigation.

3. Review and update safety management system using the principles described in chapter 18 of the HSC Code, and relevant sections of the ISM code as detailed in the Technical Requirements for the issue of a CoC and submit to PLA for approval.

4. Review functions of the DPA and passenger counting and where that information is held to ensure compliance with the principles described in Chapter 18 of the High Speed Craft Code

Port of London Authority is recommended to:

1. Undertake a review of the PLA Navigational Risk Assessment for High Speed RIB operations in central London

2. Undertake a review of the Certificate of Compliance Technical requirements

3. Should the company meet the requirements for re- issue of a Certificate of Compliance, undertake a ‘For Cause' audit three months after the Certificate of Compliance is reinstated to ensure SMS has been fully applied to the operation.

The incident is also being investigated by the MAIB.

Enforcement Action:        

MCA Enforcement leading on a prosecution under the Merchant Shipping Act.