Issued April 2021 REPORT Marine 2021/05 PART TWO REPORT ON THE COLLISION BETWEEN THE FRIGATE HNOMS ‘HELGE INGSTAD’ AND THE OIL TANKER SOLA TS OUTSIDE THE STURE TERMINAL IN THE HJELTEFJORD IN HORDALAND COUNTY ON 8 NOVEMBER 2018 Norwegian Safety Investigation Authority • P.O. Box 213, N-2001 Lillestrøm • Phone.:+47 63 89 63 00 • nsia.no • [email protected] NSIA has compiled this report for the sole purpose of improving safety at sea. The object of a safety investigation is to clarify the sequence of events and root cause factors, study matters of significance for the prevention of maritime accidents and improvement of safety at sea, and to publish a report with eventually safety recommendations. The Board shall not apportion any blame or liability. Use of this report for any other purpose than for improvements of the safety at sea shall be avoided. This report has been translated into English and published by the Norwegian Safety Investigation Authority (NSIA) to facilitate access by international readers. As accurate as the translation might be, the original Norwegian text takes precedence as the report of reference Photo (front page) of HNoMS ‘Helge Ingstad’: A. Ligaarden, Norwegian Armed Forces Norwegian Safety Investigation Authority Page 2 Table of content SUMMARY ......................................................................................................................................... 4 INTRODUCTION TO INVESTIGATION REPORT PART 2 ........................................................... 8 1. SEQUENCE OF EVENTS ................................................................................................ 11 1.1 Introduction ........................................................................................................................ 11 1.2 Sequence of events from the time of the collision until the frigate ran aground ............... 11 1.3 Sequence of events from the time of the grounding until evacuation was completed ....... 21 1.4 Operational support from land ........................................................................................... 26 1.5 The rescue operation and attending to personnel ............................................................... 36 2. FACTUAL INFORMATION ............................................................................................ 40 2.1 Introduction ........................................................................................................................ 40 2.2 Damage to the vessel ......................................................................................................... 40 2.3 Weather and sea conditions ............................................................................................... 42 2.4 Description of the waters ................................................................................................... 43 2.5 Manning, roles and shipboard organisation ....................................................................... 43 2.6 The vessel ........................................................................................................................... 50 2.7 Parties involved .................................................................................................................. 93 2.8 Safety and security arrangements for the frigates .............................................................. 95 2.9 Special investigations ....................................................................................................... 127 2.10 Relevant previous accidents ............................................................................................. 139 2.11 Implemented measures ..................................................................................................... 143 3. ANALYSIS ...................................................................................................................... 151 3.1 Introduction ...................................................................................................................... 151 3.2 Assessment of the sequence of events ............................................................................. 152 3.3 Decision support tools for stability .................................................................................. 164 3.4 Assessment of equipment protection level and shutdown state ....................................... 166 3.5 The role of the Q-deck ..................................................................................................... 168 3.6 Watertight integrity between watertight compartments ................................................... 170 3.7 Assessment of the bilge system ....................................................................................... 170 3.8 Coordination of operational support from the shore-based organisation ......................... 174 3.9 Handling of nonconformities and incidents ..................................................................... 176 3.10 Manning and competence ................................................................................................ 178 3.11 Use and updating of the frigate’s manuals and technical documentation ........................ 183 3.12 Introduction of the Norwegian Armed Forces Defence Integrated ERP System ............ 184 3.13 Overall and binding regulations ....................................................................................... 185 3.14 Importance of an independent and overall supervisory scheme ...................................... 185 3.15 Dual roles in the defence sector ....................................................................................... 187 3.16 Task and resource management ....................................................................................... 188 4. CONCLUSION ................................................................................................................ 192 4.1 Introduction ...................................................................................................................... 192 4.2 The investigations main findings ..................................................................................... 192 4.3 Other findings .................................................................................................................. 193 Norwegian Safety Investigation Authority Page 3 5. SAFETY RECOMMENDATIONS ................................................................................. 200 6. DETAILS OF THE VESSEL AND THE ACCIDENT ................................................... 210 APPENDICES ................................................................................................................................. 212 Norwegian Safety Investigation Authority Page 4 SUMMARY Part 2 of the investigation In the early hours of Thursday 8 November 2018, the frigate HNoMS ‘Helge Ingstad’ and the tanker ‘Sola TS’ collided outside the Sture Terminal in the Hjeltefjord. Approximately 10 minutes after the collision, the frigate ran aground, and subsequently sank. The frigate had a crew of 137, seven of whom sustained minor injuries. In Part 2 of the investigation, the Norwegian Safety Investigation Authority has mapped the sequence of events after the collision until the frigate ran aground, and up until she was pushed towards the shore. Interviews with the crew have confirmed that they were under considerable acute stress during and after the collision, which affected their damage control efforts. The investigation has shown that a number of factors contributed to the incident, several of which were at the organisational and systemic level. The incident The collision caused considerable damage to the frigate, and for a period it was unclear whether anyone had died. What had happened, the scope of damage to the frigate and whether it would sink were also not clear. During the period between the collision and the grounding, the bridge crew were under the impression that neither steering nor propulsion could be controlled from the bridge. Other stress factors included the collision forces and the frigate’s angle of heel, damage to communication equipment on board, and the concurrent triggering of a number of alarms. It was also dark, and the accident happened at an hour when most of the crew were asleep. The situation was more complicated and unpredictable than anything the crew had been trained to handle. The navigators on the bridge believed they had tried every option available to stop the frigate before she ran aground, but to no effect. Figure 1: HNoMS ‘Helge Ingstad’ after the collision. Illustration: CIAAS/NSIA The damage sustained in the collision caused flooding of several compartments. After the frigate ran around, water also ingressed to the reduction gear room through the hollow propeller shafts. Eventually, the flooding was considered so extensive that the frigate was deemed to be lost, and it was decided to evacuate the crew. Doors, hatches and other openings in the frigate that were supposed to be closed to maintain stability and buoyancy were not closed by the crew at the time of evacuation. The frigate subsequently sank. Norwegian Safety Investigation Authority Page 5 Damage control and stability The investigation has shown that efforts to prevent the frigate from sinking and prioritisation of the right measures could have helped to gain control of the situation on board. For the crew to be able to consider actions other than those that were taken, however,