T R O P Report on the investigation of the collision between E R the high-speed passenger catamaran T N Typhoon Clipper E D and the workboat I C Alison C A adjacent to Tower Millennium Pier, River Thames, London on 5 December 2016 H C N A R B N O I T A G I T S E V N I T N E D I C C A E N I R A VERY SERIOUS MARINE CASUALTY REPORT NO 24/2017 NOVEMBER 2017 M Extract from The United Kingdom Merchant Shipping (Accident Reporting and Investigation) Regulations 2012 – Regulation 5: “The sole objective of the investigation of an accident under the Merchant Shipping (Accident Reporting and Investigation) Regulations 2012 shall be the prevention of future accidents through the ascertainment of its causes and circumstances. It shall not be the purpose of an investigation to determine liability nor, except so far as is necessary to achieve its objective, to apportion blame.” NOTE This report is not written with litigation in mind and, pursuant to Regulation 14(14) of the Merchant Shipping (Accident Reporting and Investigation) Regulations 2012, shall be inadmissible in any judicial proceedings whose purpose, or one of whose purposes is to attribute or apportion liability or blame. Front cover photograph of Typhoon Clipper courtesy of Thames Clippers © Crown copyright, 2017 You may re-use this document/publication (not including departmental or agency logos) free of charge in any format or medium. You must re-use it accurately and not in a misleading context. The material must be acknowledged as Crown copyright and you must give the title of the source publication. Where we have identified any third party copyright material you will need to obtain permission from the copyright holders concerned. All MAIB publications can be found on our website: www.gov.uk/maib For all enquiries: Marine Accident Investigation Branch Spring Place 105 Commercial Road Southampton Email: [email protected] United Kingdom Telephone: +44 (0) 23 8039 5500 SO15 1GH Fax: +44 (0) 23 8023 2459 Press enquiries during office hours: 01932 440015 Press enquiries out of hours: 020 7944 4292 CONTENTS GLOSSARY OF ABBREVIATIONS AND ACRONYMS SYNOPSIS 1 SECTION 1 - FACTUAL INFORMATION 2 1.1 Particulars of Typhoon Clipper, Alison and accident 2 1.2 Narrative 4 1.2.1 Events prior to the collision 4 1.2.2 The collision 4 1.2.3 Post-collision events 4 1.3 Environmental conditions 11 1.4 Damage 11 1.5 Typhoon Clipper 13 1.5.1 General 13 1.5.2 Applied regulations 13 1.5.3 Crew 13 1.5.4 Wheelhouse visibility 14 1.5.5 Closed-circuit television 14 1.5.6 Man overboard equipment 17 1.6 Thames Clippers 17 1.6.1 The company 17 1.6.2 Safety management 18 1.6.3 Crew training and emergency procedures 18 1.6.4 Passage plans 18 1.7 Alison 19 1.7.1 General 19 1.7.2 Crew 19 1.7.3 Safety management 19 1.7.4 Certification 21 1.7.5 Industry best practice 21 1.8 Tower Millennium Pier 21 1.9 The Port of London Authority 22 1.9.1 Background 22 1.9.2 Vessel traffic capacity study 22 1.9.3 Thames Byelaws and General Directions 23 1.9.4 Thames Freight Standard 23 1.9.5 Commercial Vessel Code of Practice 24 1.9.6 Passenger Vessel Code of Practice 25 1.10 Maritime and Coastguard Agency Boatmasters’ Licence 25 1.10.1 Competency 25 1.10.2 Local knowledge endorsements 26 1.11 Cold water immersion 26 1.12 International Regulations for Preventing Collisions at Sea 27 1.13 Accident reconstruction 27 1.14 Previous or similar accidents 28 1.14.1 Collision between Bowbelle and Marchioness: MAIB Report dated 5 June 1990 28 1.14.2 Collision between Brenda Prior and Beatrice: MAIB Report 16/2005 29 1.14.3 Collision between Hurricane Clipper and George Williams 29 SECTION 2 - ANALYSIS 30 2.1 Aim 30 2.2 Fatigue or alcohol 30 2.3 The collision 30 2.4 Alison – lookout and risk of collision 30 2.4.1 Crew competence 30 2.4.2 Risk of collision 30 2.4.3 Normalisation of risk 31 2.5 Typhoon Clipper – lookout and risk of collision 32 2.5.1 Situation 32 2.5.2 Line of sight detection 32 2.5.3 Use of CCTV system 32 2.6 Typhoon Clipper wheelhouse visibility 35 2.7 Use of sound signals 35 2.8 Safety management of Alison 36 2.8.1 Risk assessment and safety procedures 36 2.8.2 Designating a vessel skipper 36 2.9 Emergency response 36 2.10 Survivability in cold water 37 SECTION 3 - CONCLUSIONS 38 3.1 Safety issues directly contributing to the accident that have been addressed or resulted in recommendations 38 3.2 Safety issues not directly contributing to the accident that have been addressed or resulted in recommendations 38 3.3 Other safety issues not directly contributing to the accident 38 SECTION 4 - ACTIONS TAKEN 39 SECTION 5 - RECOMMENDATIONS 40 FIGURES Figure 1 - The River Thames with detail inset of the Upper Pool Figure 2 - Locations of Typhoon Clipper, Silver Bonito and Alison prior to the accident Figure 3 - Typhoon Clipper adjacent to the pier, waiting for Silver Bonito to pass Figure 4 - Tower Millennium Pier CCTV showing Alison emerging into the river from close by the end of the pier Figure 5 - Chart showing the movement of Typhoon Clipper, Silver Bonito and Alison Figure 6 - Typhoon Clipper’s bow CCTV camera image immediately prior to collision Figure 7 - Typhoon Clipper’s DCSA throwing a lifebuoy to Alison’s crewmen Figure 8 - Typhoon Clipper’s port forward embarkation area just prior to the rescue with Alison’s crewmen in the water Figure 9 - Alison’s second crewman being rescued out of the water by Typhoon Clipper’s mate, the DCSA, an off-duty DCSA and a passenger Figure 10 - Damage to Typhoon Clipper’s port stem Figure 11 - Recovery of Alison off the riverbed with inset detail of its superstructure damage Figure 12 - Diagram showing regulation and designed sight lines ahead of Typhoon Clipper Figure 13 - Typhoon Clipper’s rear-view mirrors Figure 14 - Diagram showing approximate arcs of coverage of Typhoon Clipper’s external CCTV cameras Figure 15 - Typhoon Clipper’s wheelhouse CCTV display (during the reconstruction) showing the display settings at the time of the accident Figure 16 - Alison - detail of trumpet horn, morse controller position and lifejacket signage Figure 17 - Tower Millennium Pier Figure 18 - Figure from the Marico Marine study showing in red the area of greatest risk in the Upper Pool Figure 19 - PLA Passenger Vessel Code of Practice – passage planning in the Upper Pool Figure 20 - Accident reconstruction - Typhoon Clipper’s bow camera view showing the workboat Joanna B Figure 21 - View of the pier from Typhoon Clipper’s wheelhouse (during reconstruction) and inset analysis of Alison’s height when close by the pier Figure 22 - Analysis diagram showing Typhoon Clipper’s blind sector and Alison’s assessed relative position Figure 23 - Typhoon Clipper CCTV port side outboard forward-looking camera’s brief detection of Alison immediately prior to collision ANNEXES Annex A - Typhoon Clipper – High-Speed Craft Safety Certificate Annex B - Extract of Thames Clippers’ SMS – manoverboard procedure Annex C - PLA Safety Bulletin 1/2017 GLOSSARY OF ABBREVIATIONS AND ACRONYMS BML - Boatmasters’ Licence CCTV - Closed-circuit television COLREGs - International Regulations for Preventing Collisions at Sea, 1972, as amended CRC - Crown River Cruises Limited dB - Decibels DCSA - Deck/Customer Services Assistant DSM Code - Merchant Shipping (Domestic Passenger Ships) (Safety Management Code) Regulations, 2001, as amended HSC Code - International Code of Safety for High-Speed Craft, 2000, as amended IMO - International Maritime Organization ISM Code - International Management Code for the Safe Operation of Ships and for Pollution Prevention, 1993 LKE - Local Knowledge Endorsement LOA - Length Overall LRS - London River Services m - metres MCA - Maritime and Coastguard Agency MSN - Merchant Shipping Notice NWA - National Workboat Association PFD - Personal Flotation Device PLA - Port of London Authority RNLI - Royal National Lifeboat Institution SMS - Safety Management System TfL - Transport for London UTC - Universal Co-ordinated Time VHF - Very High Frequency Radio VTS - Vessel Traffic Services TIMES: all times used in this report are UTC unless otherwise stated SYNOPSIS At 1108 on 5 December 2016 the high-speed passenger catamaran Typhoon Clipper and the workboat Alison collided adjacent to Tower Millennium Pier, River Thames, London. Alison capsized and sank immediately; the two crewmen on board were subsequently rescued by Typhoon Clipper’s crew. Alison’s crewmen were treated at the scene for the symptoms of cold shock, then admitted to hospital for checks before being released later the same day. Alison was recovered off the riverbed the following day by the Port of London Authority; there was no pollution. Alison’s crew had unberthed their vessel from Tower Millennium Pier and headed out into the river without properly assessing the shipping situation or making their intentions clear to other vessels. When the crew of Alison became aware of the risk of collision with Typhoon Clipper, it was too late to take effective avoiding action. Neither Typhoon Clipper’s master nor mate saw Alison before the collision. This happened because Alison was initially obscured by the pier and then moved into Typhoon Clipper’s visual blind sector ahead. Typhoon Clipper’s forward-looking closed-circuit television camera captured Alison’s movements; however, this image was not being displayed in the wheelhouse. Neither of Alison’s crewmen was wearing a personal flotation device; this placed their lives in immediate danger when immersed in cold water. Alison’s owner/operator, Crown River Cruises Limited, had not conducted a risk assessment or developed procedures for the safe operation of its workboats. The investigation also identified ambiguities with the Port of London Authority’s regulations regarding the keeping of a lookout on vessels with limited visibility and the use of sound signals when departing from piers. This report makes a safety recommendation to the Port of London Authority intended to clarify the requirement for keeping lookout on vessels with limited visibility and the use of sound signals when entering the Thames fairway. A safety recommendation has also been made to Crown River Cruises Limited to improve safety through the introduction of workboat operating procedures. 1 SECTION 1 - FACTUAL INFORMATION 1.1 PARTICULARS OF TYPHOON CLIPPER, ALISON AND ACCIDENT SHIPS PARTICULARS Vessel’s name Typhoon Clipper Alison Flag United Kingdom United Kingdom Classification society Not applicable Not applicable IMO number 9451771 Not applicable Type High-speed passenger ferry Workboat Registered owner Collins River Enterprises Crown River Cruises Limited Limited Manager(s) MBNA Thames Clippers Crown River Cruises Limited Limited Construction Aluminium Steel Year of build 2007 Unknown Length overall 38.04m Not applicable Registered length 35.32m 7.25m Gross tonnage 169 tonnes Not applicable Minimum safe manning 4 1 Maximum number of 220 Not applicable passengers VOYAGE PARTICULARS Port of departure Tower Millennium Pier Tower Millennium Pier Port of arrival Canary Wharf Westminster Moorings Type of voyage Passenger ferry service Stores transfer Passengers 48 None Crew 4 2 MARINE CASUALTY INFORMATION Date and time 5 December 2016, 1108 Type of marine casualty or Very Serious Marine Casualty incident Location of incident 51°30.42’N - 000°04.69’W Place on board Port hull stem Hull Injuries/fatalities None One crewman suffered skin burns from contact with red oxide paint Damage/environmental Indentation to port bow Vessel foundered impact 2 MARINE CASUALTY INFORMATION (continued) Ship operation Inland waterway passenger On passage service Voyage segment Departure Departure External & internal Wind: south-westerly, 10 knots. Visibility: good environment Tidal stream: slack water (Thames barrier closed) Water temperature: 11ºC Persons on board 52 2 Image courtesy of Thames Clippers Typhoon Clipper Alison 3 1.2 NARRATIVE 1.2.1 Events prior to the collision At 0730 on 5 December 2016, Typhoon Clipper departed from Woolwich Pier to commence its daily ferry service, initially heading upriver to Westminster (Figure 1). After completing one round-trip up and down the river, Typhoon Clipper berthed back at Woolwich Pier for a short crew break. During that morning, the crew of the workboat Alison took their vessel downriver from St Thomas’ moorings and berthed on the north side of Tower Millennium Pier (Figures 1 and 2) to collect 10 tins of paint from the offices of Crown River Cruises Limited (CRC). After the crew rest period, Typhoon Clipper commenced its second round-trip service, berthing at Tower Millennium Pier at 1102 (Figure 2). At about the same time, the passenger vessel Silver Bonito was passing underneath Tower Bridge heading upriver (Figure 2). Once passengers had embarked, the crew of Typhoon Clipper unberthed the vessel and the master decided to wait for Silver Bonito to pass clear before proceeding ahead. Typhoon Clipper was stationary with the bow away from the pier and the port quarter close to, or touching, the pier (Figure 3). At the same time, Alison was unberthed by its crew and driven close by the end of the pier (Figure 4) then headed into the river with the intention of passing ahead of Typhoon Clipper before turning to starboard behind Silver Bonito. 1.2.2 The collision At 1107:57 and with Silver Bonito passing clear to starboard, Typhoon Clipper’s master applied ahead power and starboard rudder to head back downriver. Both of Alison’s crewmen were alerted to Typhoon Clipper’s acceleration by the sound of its engines increasing power. Alison’s helmsman immediately applied full astern in an attempt to back out of the way as Typhoon Clipper moved rapidly closer (Figures 5 and 6). At 1108:08, Typhoon Clipper’s port bow struck Alison’s starboard side abeam the workboat’s wheelhouse. Alison immediately capsized to port and sank; the crewman on the foredeck was washed overboard and the helmsman was briefly trapped in the wheelhouse before escaping free and swimming back to the surface. 1.2.3 Post-collision events The master of Silver Bonito witnessed the collision and made a “Mayday” report to the Port of London Authority’s (PLA) vessel traffic services (VTS) using very high frequency (VHF) radio. PLA VTS responded to the “Mayday” by alerting the Thames RNLI1 station, local police and ambulance services. On hearing the impact, Typhoon Clipper’s master stopped the vessel immediately by selecting full astern. Typhoon Clipper’s deck/customer services assistant (DCSA) also heard the impact and went to the foredeck to investigate. Hearing shouting and then seeing men in the water, the DCSA reported a man overboard situation to the master using the internal communications system, then threw a lifebuoy (Figure 7) that Alison’s crewmen were able to grab. 1 Royal National Lifeboat Institution 4