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Incident Investigations, Reports and Data

The Port of London's Authority's Marine Management Team (MMT) regularly reviews the Safety Management System's (SMS) performance against our three yearly Marine Safety Plan.

Below are the latest Quarterly and Annual SMS Reports which contain these SMS reviews as well as Incident Statistics and Trend Analysis.

SMS Reports

Quarterly Reports - 2018

Quarter 1

Quarterly Reports - 2017

Quarter 1

Quarter 2

Quarter 3

Annual Reports

2016

2017

 

For any questions regarding the above reports please contact the Safety Management Team at SafetyManagement@pla.co.uk

 

To make any comments or if you have any queries in relation to the PLA's compliance with the Port Marine Safety Code (PMSC) please contact our Designated Person: Ray Blair MNI, Principal Consultant, Marico Marine, Marico House, Bramshaw, Southampton, SO43 7JB  - (Ray.blair@marico.co.uk) 02380 811 133 or 07436 803674

 

Summary of Navigational Incidents in the Port of London

Introduction

An Integral part of the Port's marine Safety Management System involves the investigation of all navigational incidents that are reported to the Harbour Master. Following an initial assessment, all Navigational Incidents (those affecting or having the potential to impact upon navigational safety) are investigated further, from both a regulatory and safety perspective. Details of the incident, the investigation and outcomes are recorded in an incident database.

Serious Incidents which have been investigated by the Harbour Master are summarised below:

Other investigation reports may be available upon request.

Date Incident Description Actions
11/11/2017 A Tanker was swinging towards the berth, on departure, when her bow made heavy contact with the upper dolphin of the berth. The impact caused significant damage to the dolphin, and the starboard bow of the vessel was penetrated just above the waterline, in way of the fore peak tank. PLA to review the Pilot's training in relation to large vessels and the use of tugs to determine whether any further training is required.

Review the procedures/guidance to Pilots with regards to taking trippers.

Circulate report to all Pilots, highlighting lessons identified.

Terminal manager to review mooring procedures and consider a representative to remain at the jetty until a departing vessel has swung clear.

DPA to remind Masters of the need for good Bridge Team Management when Pilot on board.
16/08/2017 A product tanker ran aground a short distance off the Broadness Light tower after suffering a complete power failure due to contaminated fuel. Due to prompt action by the pilot and crew on board both anchors were deployed which reduced the vessel's headway prior to grounding. The vessel re-floated on the tide and was taken to Tilbury Power Station Jetty to complete a damage assessment.

The contaminated fuel tank was cleaned and dirty filters replaced.
Review Pilot training to ensure adequate training is given to prepare new pilots and refresh existing pilots on different emergency procedures.

Review Emergency Checklists.

Undertake training exercises with VTSOs using emergency checklists.
23/10/2017 A rope guard previously installed on a safety boat had picked up some debris, which then holed the vessel’s hull. A watertight bulkhead had previously been drilled through to run hydraulic hoses, however these holes were not made watertight, which, resulting in a rapid sinking.

A boom was established around the sunken vessel as there was a sheen on the water in the vicinity.
The owners of the Safety Boat were advised to reinstate the watertight integrity of the bulkhead and deck by way of watertight fittings for the hydraulic steering system. The owners of the vessel have also removed the rope guard.
08/09/2017 The supervisor loading a barge was doing so using the barge’s draught marks, not realising that the barge was aground at low water.

The barge had a 1,500 tonne capacity but was loaded with 1875 tonnes. When the tide rose the overloaded barge was not able to float with the tide and remained aground, causing it to founder whilst secured alongside a jetty.

To re-float the barge, the crane barge was used to remove part of the load into another barge and re-float the loaded barge.
Tug company to review and update the Safe System of Work procedure and introduce a stop work policy over low tide when the barge is aground.

Prior to loading operations commencing jetty operatives and lighterman to conduct a briefing on the planned tonnage (max tonnage to be posted in the conveyor control box), tide, method of communication.

Jetty Operatives to use the extension lead for the conveyor remote control to ensure line of sight with the lighterman at all times. Standby tug available whilst loading.
11/08/2017 While a mooring maintenance vessel was carrying out routine maintenance on Sea Reach No. 1 navigation buoy, two crew members suffered injuries during the recovery of the pennant chain.

Whilst heaving the chain on board it appeared to snag the anchor wire, causing he wire to be pulled across the deck. The anchor wire then snapped back, hitting the two crew members. One crew member sustained a hair line fracture to the left fibula, the second crew member sustained severe bruising to the top of his right thigh.
The Overhauling Navigation Buoy Procedure has been reviewed and updated.

Crew carrying out Tool Box Talks have been reminded to use the Tool Box Talk Pointers to aid them in reminding crew of potential hazards which have previously been identified.
16/06/2017 A cruise ship transiting the Thames Barrier inbound for Greenwich Ship Tier, with TUG 1 secured forward and TUG 2 aft, started closing on pier 7 of Delta span of the Thames Barrier. The pilot countered the closing stern with a "hard to port" helm order, to lift the stern away from the pier. The cruise ship stabilised and began to swing to port; to counter this "hard to starboard" was subsequently ordered due to the anticipated northerly tidal set. This led to the stern of the CRUISE SHIP closing again on pier 7 of Delta span, the same "hard to port" helm order was applied, but was insufficient to stop the port quarter making contact with pier 7 of Delta span.

The vessel cleared the Thames Barrier and the Chief Officer was tasked to investigate the damage and reported there were no hull penetrations. The CRUISE SHIP continued on passage to Greenwich Ship Tier without further incident. The Harbour Service Launch remained in attendance throughout conducting local traffic control.
The PLA has reviewed the risk assessment for vessels over 210m length overall navigating above the Thames Barrier with regard to the lessons identified following this investigation and developed a revised methodology for Thames Barrier transits at 2-3 knots SOG that allows the primary pilot to position on the bridge wing, which pilots will also undertake in a simulator prior to the voyage and annually in a variety of environmental conditions. Cruise ship captains will be invited to attend.

A Protocol has been developed to support the changeover of conduct from the Primary to Secondary pilot during the change of controls from the central to bridge wing positions and increase PPU tripping for River Pilots and standardise the way information is passed to ensure effective communication.

Establish the Thames above Margaretness as a high-risk area and ensure all non-essential personnel are clear from the bridge. This should form part of the Pilot/Master Exchange.
05/05/2017 A Dutch Barge lost propulsion and drifted towards London Bridge.

A river patrol vessel assisted and made an approach to the barge with the intention of taking the vessel alongside. The Master of the Dutch Barge was standing on the deck of the barge intending to receive a line and due to significant wash both vessels rolled towards each other and the Master of the barge was caught between the vessels.

Despite the crushing injury the Master was able to make the line fast. The patrol vessel manoeuvred the vessel alongside the PLA driftwood mooring at New Fresh Wharf.

The RNLI attended and treated the Master for a fractured pelvis before taking him to Tower Pier where he was transferred to hospital.
The PLA will produce a Safety Bulletin highlighting the need for adequate engine trials before undertaking voyages on newly repaired engines.

The Towage Risk Assessment and method statement for the river patrol vessel is to be reviewed and updated and formal towage training provided for crews. CCTV is to be installed on the vessels in future.

The Master of the Dutch Barge was advised of the importance of comprehensive engine checks following substantive engineering works and danger zones during towing operations.
03/04/2017 A Class V vessel had experienced engine difficulties during the afternoon, which was reported to their base, however the Master declined a replacement vessel, believing it safe to continue.

The vessel's starboard engine then failed causing the vessel to make contact with the No. 4 arch of Southwark Bridge. This caused significant damage to the superstructure of the vessel. The engine was successfully restarted once clear of the bridge and the vessel returned to base without further incident.
The PLA has recommended to the operator that they review their procedure for withdrawing vessels from service in the event of machinery failure by the operations team and also conduct a full review and audit of the CCTV systems on all vessels, to establish that they are in good working order.

The Master has received a verbal warning for not supervising the unqualified Mate on the helm and the operator has been advised to review procedures to ensure that if an unqualified crew member takes the helm, they are directly supervised by the Master at all times.

The PLA will be performing spot checks on vessels to ensure a qualified person is at the helm, or a qualified person is providing dedicated supervision to unqualified crew at all times in compliance with PLA General Direction 18.
25/03/2017 12 Inward bound Rowing Eights were racing each other with the flood tide in a private rowing race from Nine Elms Reach to Putney Hard.

Whilst in Chelsea Reach, four Rowing Eights were abreast of each other and one of these crews was unaware of the middle abutment of Albert Bridge.

A number of coaching launches attempted to make the Cox aware of this but to no avail. The Eight struck the abutment resulting in the bow being broken off and the crew entering the water. The crew was rescued with no reported injuries.

The Eights were also involved in a Near Miss with a Tug and Tow at Cringle Dock.
The Thames Regional Rowing Council (TRRC) banned all involved from waterborne activities, with all coxes and coaches resitting tideway endorsement examinations.

The TRRC will be improving the content of annual safety inductions and organise annual cox and coaches refresher training. An Annual Coaches Forum will be looked at being developed.

The TRRC will consider reviewing sanctions and procedures available to the TRRC and future contingency options for all Head of the River Races.

The Rowing Code has been amended as follows:
  • Crews proceeding below Wandsworth Bridge, regardless of tide, must have the outing plan pre-approved by the Club's Rowing Safety Advisor.
  • Restriction on rowing below Fulham Railway Bridge extended to two hours after high tide.
Those involved were issued with Harbour Masters Warnings – The Cox under Section 108 of the Port of London Act and the organising Coach under failure to comply with Thames Byelaw 9.
05/12/2016 A Class V Passenger vessel collided with a workboat below Tower Pier. The Class V Vessel was holding position approximately 3-4m from pier face waiting for another vessel to pass before proceeding. The workboat had departed the inside face of Tower Pier and crossed the front of the Class V Vessel just as it began to move ahead.

The vessels made contact and pushed the workboat over and sank almost instantly. The workboat crew were recovered by the crew of the Class V vessel. Both were attended to by the London Ambulance Service and were taken to Hospital for precautionary checks.

The PLA recommends that the operator of the workboat develops familiarisation training for crew, concerning ColRegs and Byelaws and to identify methods for improving the safety culture across the company.

The Class V Operator is recommended to revise internal procedures for conducting a visual check when departing piers and to consider future visibility requirements in new build vessels. The lessons identified will be shared with all crews.

The PLA will enforce wearing of PPE in commercial craft utilising the Harbour Service crew and develop a pre season training and briefing package incorporating lessons learnt from this incident.

A safety bulletin focusing on effective communication and keeping a good lookout has been produced.

This incident is subject to a further MAIB investigation with the report expected to be published during the Autumn of 2017.

24/11/2016 A motor tug made her way from Rainham across the river to Erith Causeway to drop off a member of crew.

As they came alongside he failed to stop the tug in time and landed heavily on the causeway with the shoulder of the tug, causing significant damage to the causeway.

Written warnings have been issued to both members of the crew and educational letter has been sent to the operator and copy of the report to the MCA.

The crew has been reminded that deck logs must be filled in at all times and that all incidents must be reported to the PLA.

A van has been issued to one of the crew in order to avoid the necessity of using vessels.

03/08/2016 A cruise ship was berthed port side alongside at London Cruise Terminal and was preparing to undertake an ebb tide departure with a pilot onboard.

As the vessel manoeuvred off the berth she failed to sufficiently clear the landing stage before coming ahead which put her into conflict with a ferry berthed ahead of her. The pilot onboard the ship contacted the ferry and instructed the vessel to vacate her berth. The Master of the ferry, who had been watching the departure of the cruise ship had anticipated the danger and was quickly under way. However due to the close proximity of the vessels the ferry was unable to manoeuvre sufficiently clear and the vessels made contact.

No injuries were sustained from any persons on either vessel nor was any pollution reported.
  1. A letter has been sent to the ferry operator, with regard to the ferry keeping clear of the landing stage when large vessels are manoeuvring on to or off it.
  2. The investigation report has been sent to London VTS and Pilots, highlighting the lessons identified.
  3. The ship will re-take the tug assessment for an ebb tide departure, giving further consideration to the wind limits that should be applied.
  4. The PLA will investigate the feasibility of installing equipment to measure and record gusting wind strength.

 

Classification of Navigational Incidents in the Port of London

Navigational Incidents reported under the PLA's marine Safety management System are classified by severity as follows:

Minor Incident: Incidents, which do not affect persons and have a negligible cost implication (<£5K) 

Serious Incident: Incidents which may involve slight/significant injury to persons and have a moderate cost implication (>£50K)

Very Serious incident: Incidents reported to the Board, which involve serious injury or fatality and have a serious/major cost implication (>£2M)

Incidents are categorised as follows:

Contact
Floating Hazard
Collision
Pilot Ladder Deficiency
Grounding
Vessel Equipment Deficiency
Loss of Hull Integrity
Vessel Navigation Aid Deficiency
Swamping
Foreshore Incident
Pollution
Criminal/Malicious Damage
Fire/Explosion
Man Overboard
Near Miss
Safe Access Deficiency
Innappropriate Navigation
Port Security Incident
Navigational Hazard
Other
Breach of Byelaws
 
Wash
 
Breach of General Directions
 

 

Trend Analysis Reports
Please click on the links below.