Better late than never.
Luxembourg's flag state report on the sinking of the RAmpage 5000 design anchor handling tug Bourbon Rhode on September 26, 2019, was finally issued on April 15, 2021. You can read the full 106 pages here.
The report was buried deep within the Grand Duchy's Department of Transport website and its release was completely missed both by us and by most of the maritime industry press. In fact, the insurance industry took more notice than the marine industry (here), because ships sinking actually cost the insurers money, whereas for the owners the loss of a vessel is often just an inconvenience and some more paperwork, even when seafarers have perished. This is a sad fact.
You'd almost think the Luxembourg authorities didn't want people to find their investigation. The report is prefaced by the usual warning that "the sole objective of the safety investigation and the Final Report is the prevention of accidents and incidents."
But does the report even meet this noble aim? We have some suggestions for improvement for the Grand Duchy's flag state authorities themselves.
First, some background.
Bourbon Rhode sank approximately 963 nautical miles east of the coast of French Guyana and 896 nautical miles west of Cape Verde whilst sailing through the middle of Hurricane Lorenzo, a category three storm with sustained wind speeds of 110 knots.
Eleven crewmembers died when the vessel was lost in the tropical storm on September 26. The fatalities included the Croatian captain and the chief engineer. Just three seafarers, two Ukrainian able seamen and a Russian fitter, were rescued from a life raft two days later. None of the ship's officers lived to give testimony to the investigators. Only the captain had worked on the vessel before.
Bourbon Rhode was a modern anchor handler, 49.5 metres long, built at Keppel Singmarine in Singapore in 2006 to a Robert Allan Ltd design, with just under 6,000 kW of main engine power. At the time, Bourbon was the largest operator of offshore support vessels in the world, but had lost hundreds of millions of dollars in the years preceding the sinking, and soon afterwards would be restructured and taken over by its banks.
Sister ships appear to have operated around the world without incident, and the vessel was neither old nor small by offshore industry standards.
Bourbon Rhode had just completed a six-week-long drydocking in the Canary Islands and was en route to start a new charter in Guyana with Saipem. She departed on September 17, in calm seas and fair weather. The vessel was classed by Bureau Veritas. Underway, one of the engines was stopped twice for a couple of hours on September 21 and 22 for maintenance.
The vessel had previously been operating in Nigeria for twelve years, and as a Nigerian-flagged vessel since 2014. This is critical. The vessel changed flag to Luxembourg four days before it sailed from Las Palmas, and less than two weeks before it was lost. In terms of duration on the register before disaster struck, Bourbon Rhode is up there with Titanic on its ill-fated inaugural voyage. Why did Luxembourg even accept the vessel? And what quality control was undertaken by the flag state?
Luxembourg as a flag state is ranked as a white list flag state by the Paris MOU and as grey list by the Tokyo MOU based on the performance of vessels under its registry in port state inspections. Nigeria is not ranked at all by either the Paris MOU or Tokyo MOU, which means many serious charterers, for instance TotalEnergies, will not accept Nigerian-registered vessels to work for them, except inside Nigeria, where they have no choice.
Choosing to accept the vessel from a flag state like Nigeria would seem to have been a major error on the part of Luxembourg, albeit not material to the sinking.
The report is very detailed on the minute by minute events that led up to the loss of Bourbon Rhode. There is much harrowing information on the tragic moments leading up to the sinking, as the vessel took on water in horrendous seas. The vessel entered the storm zone on the morning of September 26 and began to roll heavily. Visibility reduced, the wind moved from gale-strength to storm force to full-on hurricane force 12 on the Beaufort scale and the sea state rose accordingly. Water was entering the Z-drive room through a leaking inspection hatch from the shark's jaws compartment under the anchor handling deck.
"The engine crew was using a portable electrical suction pump to pump water out of the Z-Drive compartment, leading the hoses to the adjoining hold compartment," the investigators noted. "In addition, they used buckets to speed up the process. According to survivor statements, the chief engineer had reported that water was entering the Z-drive compartment through the inspection covers of the shark jaws housing frame."
Then, the tug's pumps failed, the engine room filled with water, and the tug lost power and floundered. The captain issued distress messages to the ship manager in Europe, who was powerless to help.
The investigation team used the ship's engine fuel monitoring system, which was automatically reporting by satellite, to document the steady deterioration of Bourbon Rhode's condition as the engine room flooded, slowly at first, then quicker and quicker. One by one the main engines and then the generators shut down and failed, leaving the vessel adrift in violent seas.
You can sense the fear and terror from the testimony of the survivors, and from the email exchanges, as the situation deteriorates. One chilling email from the tug at 09:57 reads as follows:
"We have no more engine, they are all down. All crew muster, ready and on standby… Life rafts not possible to launch, very rough sea, swell 10 metres or more."
Finally, the last message sent from the ship at 12:28 reads: "Z-drive isolated/Engine room isolated. The water is increasing."
Then there was silence. The next email from the ship manager was not delivered. We presume that the vessel sank in the period between the two emails, probably around 12:30.
The report described the chaotic and awful scenes as the crew abandoned ship in the middle of the massive storm, the wind and the hurricane raging around them. Five men managed to grasp the external lifeline of an overturned life raft nearby, but two were washed away during the hurricane and perished. The three survivors managed to right the life raft in relatively calmer seas when the eye of the storm briefly passed over them.
A search and rescue mission was launched and various Good Samaritan vessels assisted, along with planes and helicopters from Martinique. The bulk carrier Piet recovered the survivors.
The Grand Duchy published an interim safety bulletin from the accident in August 2020, which we highlighted here. This explained the sinking caused by water ingress through the inspection openings of the shark's jaws into the Z-drive compartment at the stern.
The interim report provides more detail on the problem, noting that, "in the event of flooding of the Z-drive compartment, it can be assumed that contact of the electrical components with water would lead to a short circuit and thus affect the ability of the vessel to maintain propulsion and steering."
The report further notes that "the steering system and electrical cabinets were positioned on floor plate level. The cabinets were open at the base and thus left the electrical components unprotected against water in case of flooding."
Tests on sister vessel Bourbon Rhesos showed the catastrophic impact of such a loss of power.
Shockingly bad maintenance was clearly a factor in the sinking. Owners had known that the seals on the inspection covers for the shark's jaws compartment were defective since March 2019, six months before the ship sank. The Luxembourg report shows photos from the technical inspection of the leaking, not at all watertight, hatch, rust marks from salt water ingress staining the paint.
The investigators found that "the technical inspection performed on March 8, 2019 identified the need for new covers for the anchor handling system (shark's jaws, towing pins and cable lifter) to be fabricated. The standard procedure defined by the manufacturer is to install the inspection covers with a rubber gasket or silicone sealant and secure them by bolts in order to establish watertightness."
The Bourbon crew on the voyage from Nigeria to Las Palmas for docking noted the same problem and entered the item into the vessel's maintenance system as work that should be done during the docking. It wasn't done, nor was much other work from the docking list, due to a shortage of materials and tools.
The situation was worse than just the sealings on the shark's jaw inspection hatch.
The Luxembourg report stated that Bourbon Rhode "did not make a good impression upon boarding at the shipyard. All three survivors stated that they were surprised by the bad condition. One survivor stated that a senior engine crewmember was worried about the technical state of the vessel not being in a condition to cross the Atlantic."
One of the luckiest men alive must be the chief officer who was originally assigned to the ship. He was so appalled by the condition of the vessel that he walked off the ship and left, thereby saving his life.
The investigators found that "the initially mustered chief officer left the shipyard due to the bad condition of the vessel. The replacement chief officer also complained about the overall state of the vessel."
So the ship was in lamentable condition when it arrived in the shipyard under the flag of a very dodgy flag state. Bourbon Rhode wasn't subject to a port state inspection upon arrival in Las Palmas. Given that the Nigerian flag state isn't even recorded under the Paris MOU, perhaps it should have undergone such an inspection?
The Paris MOU shows that white-listed country vessels were inspected thousands of times. Nigerian-flag vessels and other rare and unusual flags turning up in the Paris or Tokyo MOU countries might perhaps require more scrutiny? You'd think so.
The report makes a number of curious statements:
"Upon departure, the vessel was considered to be in fair condition and generally ready to sail… After leaving Las Palmas: upon departure on 17 September in Las Palmas, the vessel was considered to be generally ready to sail and watertight, except for the engine room skylight hatch, which had not been repaired during the dry dock stay."
Writers should never use the passive voice, we are told, because it obfuscates the responsibility for what happens. The vessel was considered to be in a fair condition, by whom exactly?
As for "watertight," this was a ship that sank nine days later with the loss of eleven lives, so clearly it wasn't watertight, even though the annual classification and statutory surveys were completed on September 13, 2019 with no recommendations from the BV surveyor.
The investigators seem to have followed the train of logic that perhaps a leak from the shark's jaws compartment into the Z-drive compartment might be of interest to class. Page 56 of the report contains a depressing piece of buck passing from BV, explaining how the load line certificate was originally issued in 2006 and that everything was fine then:
"The continuity of the deck integrity and watertightness are assured. Furthermore, tests with a water jet performed during the initial visit confirmed this. Hence, the shark jaw system was not considered as part of the load line inspection and does not appear on the related report."
You will note the use of the passive voice here as well. The watertightness is assured by whom exactly?
Remember when she sank, Bourbon Rhode had fresh statutory and class certificates and had just passed an intermediate docking survey. The Luxembourg authorities note that the annual survey should include the "means of closing and securing the weathertightness of miscellaneous openings in freeboard, superstructure and exposed decks (cargo hatchways, other hatchways and other openings)."
Hmm…
Our initial theory had been that perhaps commercial pressure had been applied by Bourbon to the master to meet a tight on-hire deadline in Georgetown for the new chart, or that the vessel lacked the bunkers to route around the storm.
Fortunately, neither of these theories seems to be true. Luxembourg says that the ship was only due to go onhire to Saipem in December, so there was more than seven weeks between the expected arrival in Guyana and the start of the next charter there. The report also states that the ship loaded over 440 cubic metres of fuel in the Canary Islands just before departure, so there was ample fuel onboard to re-route around the storm if required, as the ship was burning less than 12 cubic metres per day.
Poor navigational routing seems to have played a critical factor, although the report is unclear on what weather warnings the vessel received, partly because its satellite communications had failed two days out of Las Palmas. Therefore, the captain may not have had accurate weather routing information in the days before the tug encountered the hurricane. This is critical because the vessel was moving at less than eight knots during the days before it hit Hurricane Lorenzo, but the storm was moving at 15 knots by September 25. Even at maximum speed, the tug could not outrun the storm.
Bourbon's guidance, according to the report, was that "ideally, a vessel should 'ride' heavy weather on a course and at a speed to maintain heading while limiting the effects of breaking seas and to prevent damage. A full risk assessment shall be carried out prior to onset of heavy weather."
Of course, if in doubt, hold a risk assessment. This is the modern offshore mantra.
Undoubtedly, a functional satellite system and timely weather forecasts could have helped the master navigate Bourbon Rhode to safety, rather than plodding at just over seven knots into Force 12 seas.
Hindsight has twenty-twenty vision, and me harping on about lessons learned won't bring back the eleven seafarers who drowned when the tug sank. Older and wiser people probably have their own ideas on how we can learn from this tragic, utterly needless sinking
But for me, there are some clear messages:
We can only hope and pray that there isn't another sinking like Bourbon Rhode. It shouldn't happen again and it shouldn't have happened in the first place in 2019. Vessels should not be sailing towards hurricanes with no satellite communications and no weather forecasts, and with water ingress possible into the engine room for want of basic silicon sealing materials.
Luxembourg's report is better late than never. We can only hope that all other flag states disseminate the findings of their own accidents and losses openly and transparently as well. Preventing future accidents is much better than trawling through grim reports on unnecessary deaths at sea.
Background reading
The Luxembourg report highlights that industry body IMCA had already released Safety Flash 24/17 in October 2017, which highlighted the dangers of water entering the steering compartment of an anchor handler through the karm fork seals. It was eventually pumped out and the vessel and crew suffered no harm. You can read the report here. Once again, IMCA's excellent reporting leaves many flag states behind.
We first highlighted the problems of flag state reporting in a two-piece series on the loss of loss of the jackup liftboat Teras Lyzahere and a follow-up piece on the loss of Bourbon Rhode here.
In April 2021, another jackup liftboat, Seacor Power, turned over and sank in bad weather in the Gulf of Mexico with the loss of thirteen lives. We covered this here. Our coverage of the Seacor unit sinking finally led the Singapore DOT to update us on their accident report into the Teras Lyzacapsize – an update that they had agreed with the Philippine authorities that MARINA in Manila would issue the accident report, not Singapore as flag state, as we highlighted here. This investigation report has still not been issued by MARINA, to our knowledge.
Then in May this year came the worst accident in the history of the offshore industry for more than thirty years: the sinking of the Afcons Infrastructure owned accommodation workbarge P-305. The unit sank 35 nautical miles off Mumbai on May 17 during Cyclone Tauktae, after its mooring parted and it collided with a platform. The barge was chartered to India's state oil company Oil and Natural Gas Corporation (ONGC), which botched the demobilisation of its offshore units from the path of the storm, leaving several rigs, tugs, and barges in harm's way.
There were 186 survivors from P-305, but 75 crew and ONGC contractors were dead and missing when the barge went down in 90-knot winds and horrendous sea conditions. India Today has excellent coverage here.
Another 11 crew died on the anchor handling tug Varapradha, which lost its anchors and drifted in the cyclone for nearly a day off Mumbai before the engine room flooded and the ship sank. The bilge pumps on board were put out of service and the crew attempted to manually bale out the water before the tug went down.
"The water gradually filled in the engine room and by afternoon I told Captain Nagendra Kumar that the situation is out of control and pleaded with him to inform our company and other authorities like Indian Coast Guard and Navy. Kumar sent the distress call only at 5 pm or 5.30 pm to the Maritime Rescue Coordination Centre. I believe there was a delay on his part in sending the distress call," the chief engineer told The Indian Express (here). He was one of just two survivors.
We aim to cover this story of the horror on the Bombay High oilfield if and when the Indian flag state releases its report.