On September 26, 2019, the anchor handling tug Bourbon Rhode sank whilst sailing through the middle of Hurricane Lorenzo in the Atlantic whilst en route from a drydocking in the Canary Islands to start a charter in Guyana. The loss of the vessel caused the death of eleven of the fourteen seafarers on board, including Dino Miškić, the vessel's Croatian master. Three survivors were plucked from a life raft after the storm and rescued by the French navy. Only seven bodies were ever recovered.
We highlighted the need for a thorough investigation by Luxembourg, the vessel's flag state, here, to prevent such an accident ever happening again, and to provide the families and loved ones of the dead with closure on how and why they perished. For nearly a year, official silence prevailed.
Then, eleven months after the tug sank, Luxembourg finally published a safety bulletin in August (here), and a safety recommendation (here). Peculiarly, these were only linked in the French version of the Department of Transport website, not the English one.
These documents are not a final investigation report, and do not definitively address why the ship was lost. They simply highlight "a safety issue that requires an immediate safety action" arising from the ongoing investigation by the flag state authorities.
The International Institute of Marine Surveying was quick to declare that this "crucial safety flaw is [a] key finding of investigation into Bourbon Rhode sinking and fatalities" (here). We disagree. The final investigation needs to dig deeper.
The Luxembourg bulletin highlights that Bourbon Rhode was equipped with shark jaws for anchor handling, just like every other anchor handler built since the 1970s, very few of which have sunk for factors relating to that equipment. In fact, none that I can recall. There are other sister vessels of the same RAmpage 5000 ZM tug design still in service for over a decade, according to the designers (here), including Smit Angola, Seabulk Angola, Smit Siyanda, Lamnalco Griffin and identical sister vessel to Bourbon Rhode, Bourbon Rhesos.
The authors of the report explain that "when operating, water from the deck can enter the watertight housing frame, which has three drain fittings at the bottom plate. When not in use, the shark jaws are lowered into the housing frame and sit flush with the deck. In the lowered position, gaps around the shark jaws allow water to enter the housing frame."
So far, so normal, thousands of offshore vessels have this equipment with a similar design.
The report continues, "During anchor handling activities, the manufacturer recommends maintenance of the shark jaws to be carried out once every week. One maintenance item is to remove the inspection covers at the side of the housing and to clean and remove sand, mud or any obstructions from the inside of the housing frame. Upon completion of the maintenance, the inspection covers are to be installed with silicone sealant/gasket."
Again, this is highlighting standard maintenance practice carried out across the world, and not just on the Plimsoll Smith Berger Hydraulic Shark Jaw system which was fitted on the casualty.
The Luxembourg report then drops a tantalising zinger:
"Over time, the inspection covers of the shark jaws housing frame on the Bourbon Rhode have lost their watertight properties. The water leaking through the gaps between the housing frame and the inspection covers was collected in the bilge well at the bottom of the Z-drive compartment and could be pumped out by activating the bilge pump system. The investigation has shown that under unfavourable circumstances, and in combination with other safety-related factors that will be developed in the final report, the water quantity penetrating the compartment is likely to increase up to a point where, when unnoticed or unattended for a certain period of time, an unsafe condition may develop and lead to a major flooding with subsequent foundering."
Presumably, this insight must have come from testimony from one of the survivors. It makes sense that an inspection cover for the sharks jaws could leak into the neighbouring compartment if not correctly sealed, but this raises more questions than it answers. Why was the water washing on deck sustainedly in the first place? Presumably, because the vessel was navigating through a massive and violent hurricane. Why was the tug there?
Why could the water not be pumped out by the bilge pumps? Were the bilge pumps actually working? Why could the inspection hatch not be sealed once the leak was discovered? What are these "unfavourable circumstances" and how did the crew of Bourbon Rhode find themselves in such a perilous situation?
It is critical that the final investigation report must address these other "safety-related factors". These are much broader than just some missing silicone.
Then came another blow:
"During the investigation, further analysis by the operator has identified other anchor handling vessels in his fleet with leaking inspection covers of the anchor handling systems. This shows that the compromised watertightness of the anchor handling systems equipped with this type of inspection covers is not an isolated safety issue, but is likely to be encountered at a systemic level." (our bold highlight)
This finding was accompanied by illustrations of the compartment and inspection cover from Bourbon Rhesos, the identical sister vessel, also built in 2006. The operator clearly means Bourbon in this context, but this finding must cover more than just that one ship, as it uses the plural.
The Luxembourg Safety Bulletin concludes that "as an immediate safety measure, it is recommended to put in place an additional safety barrier through the SMS by implementing a procedural defence to limit the risk of flooding from leaking inspection covers of anchor handling systems."
More paperwork is required, not unsurprisingly. Have you ever seen a report which recommends that maybe the burden of filling in multiple forms and managing unwieldy safety management systems is a problem for crew?
Along with the existing maintenance instructions, the Luxembourg report notes the following as safety actions to be taken:
I am not going to criticise the findings above. Maintaining the watertight integrity of ship is the prime goal of all aboard, and of industry regulators and ship managers. These recommendations are sensible, but we should not mistake them for a definitive explanation as to why Bourbon Rhode sank.
Anchor handlers in the North Sea and elsewhere routinely face wash on the back deck in bad weather, which leads to water ingress into the sharks jaws compartment. The Luxembourg investigators' photos of the Plimsoll system on Bourbon Rhesos are completely unremarkable. The safety bulletin fails to highlight what made the situation of Bourbon Rhode different and unique such that the vessel sank. What went wrong?
As we discovered when looking at financial shenanigans in the offshore sector (here), what is not said is often more important than what is said. Rather than being satisfied that negligent maintenance on the inspection cover by the crew of Bourbon Rhode is the root cause of the loss of the vessel and the loss of their own lives – a convenient position which blames the victims and exonerates everyone else ashore – the final Luxembourg report needs to address the much wider context of the vessel's sinking.
Remember that in 2019 Bourbon was in a desperate financial plight and faced serious constraints on its ability to spend money. Charterers have used the industry downturn to impose onerous and punitive charter party terms on vessel owners. Critical points which should be addressed include:
We commend Luxembourg for issuing this safety bulletin, which is far more than Singapore did as flag state for the sinking of the liftboat Teras Lyza (here). Indeed Singapore, shockingly, has not issued a single accident investigation since July 2019!
But we should not mistake these safety recommendations from Luxembourg as a definitive explanation into the sinking of Bourbon Rhode. The root cause of this tragedy is likely to lie on the decision to route the ship through the hurricane and the condition it was in then, rather than what happened when the stricken vessel found itself literally in the eye of the storm. By then, it was too late.