Fatal Allision with Drilling Rig in Botlek Harbour

Risk management of complex operations at the shipyard run by Damen Shiprepair Rotterdam in the Botlek harbour district requires improvement. In particular, a more thorough approach is needed for complex operations that are carried out simultaneously. The shipyard must ensure that risks are clearly understood and managed. To identify risks effectively and in a structured manner, it is crucial to take account of different perspectives, particularly in the case of simultaneous operations. All the parties involved must jointly go through scenarios in advance, identify the risks that may arise, and agree on the options for taking action.

These are the conclusions of the Dutch Safety Board after an investigation into a collision between a crane vessel and a drilling rig in February 2024, in which a shipyard employee was crushed to death.

Testing assumptions and speaking out about possible risks

Erica Bakkum, boardmember: ‘Pilots must prepare themselves well for the safe execution of complex activities such as docking a crane vessel. For example, they must continuously test assumptions among all those involved and speak out about possible risks. The Regional Pilotage Corporation Rotterdam-Rijnmond is responsible for ensuring that pilots indeed prepare in this way.’

Recommendation: closer cooperation

One of the Dutch Safety Board’s recommendations is that the shipyard, the Rotterdam-Rijnmond Regional Pilotage Corporation, and the owner of the vessel should consult each other in advance when complex, simultaneous operations are involved. This will result in a comprehensive overview of all the operations at the shipyard and allow them to identify potential risks, discuss various scenarios, and make arrangements for how to communicate with one another.

Recommendations

During complex operations on or close to Damen Ship Repair’s terrain, the responsibility for risk management lies with the shipyard, especially when simultaneous activities are taking place. Together with the other parties involved in preparing and executing complex operations, the  shipyard should make the risks involving those operations (both separately and simultaneously) apparent and manageable. The other parties involved hold the shared responsibility to take care this happens. This applies in particular if parties deviate from previously made agreements about the execution and operation, for example the exceeding of wind limits. We have written recommendations for all parties together and for Damen, the Rotterdam-Rijnmond Regional Maritime Pilots Corporation and Saipem separately.

Recommendations

During a complex operation such as docking the Saipem 7000, the various parties involved can achieve safety gains if they focus on their shared contribution to safety.

To Damen Shiprepair Rotterdam, the Rotterdam-Rijnmond Regional Maritime Pilots Corporation and Saipem

1. Ensure that the various parties involved in complex operations speak to each other in advance and together, in order to gain an overview of the various activities on the site, explore possible risks, discuss different scenarios and make agreements about communication.

Following this incident, Damen Shiprepair Rotterdam has already taken a number of actions to improve safety (see Appendix B). These actions are in line with the learned lessons from this incident and are primarily focused on risk management while docking in and out. In addition, it is important to pay attention to managing the risks of all complex operations that take place on the shipyard simultaneously. This is why the Dutch Safety Board proposes the following additional recommendations.

To shipyard Damen Shiprepair Rotterdam

• Ensure a structured approach to manage risks during operations that take place simultaneously on or close to the shipyard and are able to influence each other. Involve all relevant parties in risk management, for separate projects as well as for a combination of projects. Discuss the different scenarios that can arise and how these risks should be managed. Record this approach.
• With all parties involved, make a joint reassessment of all risks if there is a deviation from previously made agreements for the execution of simultaneous operations. If necessary, adjust scenarios for risk management.
• Update and improve the Life-Saving Rules following this incident and let employees actively participate in the implementation of them. Emphasise the importance of safety as a shared responsibility.

In the Netherlands, pilotage is mandatory in certain waterways. This pilotage requirement is filled by one party, namely the Maritime Pilots (Region Scheldemonden is an exception. Here part of the mandatory pilotage is fulfilled by the Flemish pilotage service). This monopoly position entails a strong responsibility to pilot and manoeuvre vessels as safely as possible. The Dutch Safety Board therefore recommends the following:

To the Rotterdam-Rijnmond Regional Maritime Pilots Corporation

• Evaluate and improve the procedures in the Vademecum based on the lessons drawn from this incident, that ensure a proper preparation of special transport, including which tools should be used. In any case, make sure that:
• these procedures are known by the pilots and they comply by them;
• the available and most recent information is easily accessible for the pilots;
• the pilots make sure that the involved parties (like the shipyard and the captain) are aware of the assessments and choices they make during the preparation and execution of complex operations, so those parties can indicate where necessary if any risks arise.
• If voyages are made by more than one pilot, ensure that the involved pilots prepare and execute the voyage together. They need to:
• get involved simultaneously for the preparation and have the same information;
• be able to address each other professionally about managing risks in the preparation (for example during simulation training) as well as the execution of the operation, and make their assumptions explicit (for example by ‘thinking aloud’);
• ensure effective use of NMS while performing complex operations.

The client of a docking operation plays an important role in the way risk management and the execution of the operation are carried out. That is why we recommend the following:

To Saipem

• Ensure the captain, his team on the bridge and the pilot(s) jointly make specific agreements about the execution of the docking operation, so everybody knows how the operation is carried out and which task they have. Record in the agreement: the division of tasks, way of communication, different scenarios and how to deal with questions, doubts and ambiguities during the operation.
• Check with the shipyard whether they understand the risks of a complex (simultaneous) operation such as the docking operation. Make this step part of the preparation for complex operations.