Incident investigations, reports and data

On 23 November 2024 at approximately 02:00, an emergency services vessel hit a mooring buoy at high speed on the River Thames. The vessel departed its home berth near Waterloo Bridge at 01:53, tasked to an incident at Battersea Bridge. Whilst proceeding inbound to the incident location, the vessel collided with the lower mooring buoy at PLA Kirtling Barge Roads. The resultant impact holed the starboard side of the fibreglass hull at the waterline.

The Helmsman and two crew members did not suffer any injuries. Other assets were tasked to the original incident at Battersea Bridge. The vessel proceeded to Cadogan Pier where the crew could preliminarily assess the damage sustained. Upon finding a significant ingress of water, the crew started portable salvage pumps to extract the water. Additional emergency services vessels responded to assist the casualty vessel, with additional portable salvage pumps. Attempts to extract the water were unsuccessful. As a result, the casualty vessel was beached at Battersea Church Drawdock where the damage could be fully assessed. 

Contributing Factors:

 • The vessel was proceeding at maximum speed to the task at Battersea Bridge, for the majority of the passage up until the incident, the lifeboat was proceeding in excess of 40 knots and at the time the vessel made contact with the mooring buoy, they were proceeding at 41.1 knots. At this speed the Helmsman did not have sufficient time to take proper and effective action to avoid collision. 

• The Helmsman was undertaking the operator’s structured competence-based training program to develop up to commander. As part of their development, it was agreed with the duty shift Commander they would take the role as Acting Commander for exercises and routine taskings. On the 23rd November 2024, the Acting Commander on the helm, had yet to complete the operator’s Local Knowledge module, which is a requirement of the Master of the vessel.

 • Masters of certain vessels defined in Thames Byelaw 22 and Thames Byelaw 16 require a Local Knowledge Endorsement (LKE) due to the challenging conditions to navigate within this area. Navigating at high speed requires a high level of competency with local knowledge as reaction times are reduced, and the requirement to plan ahead is increased. Within the Local Operating Procedures of the vessel operator, there is a requirement for crew members to obtain the PLA LKE, which has not been enforced. The crew member on the Helm did not hold an LKE. 

• Additionally, LKEs are required to be revalidated every 5 years by completing an Oral Exam with a PLA Examiner. This is to ensure the competence of the holder is maintained, taking into account changes of the tidal Thames within the LKE area. The commander previously held a PLA LKE, however, this was allowed to lapse in November 2023 due to the Commander no longer being full time with the vessel operator. Without a revalidation, it is unknown how up to date their local knowledge is. 

• The vessel’s commander had the role of “seat 2” on the vessel for this tasking. This meant that they maintained communications with HM Coastguard and other emergency services. Due to wind noise which made communications hard to hear over the radio headset, the commander ducked down behind the console to listen. This resulted in them losing situational awareness, navigational oversight and prevented them from acting as lookout. This function could not have been performed by the crew member in seat 3, as their view was fully obstructed. 

• As a vessel is rounding Westminster Boating Base inbound, the next visible reference point is the navigation lights of Victoria Rail Bridge arch 2. This course will navigate the vessel directly over the charted position of PLA Kirtling Barge Roads. With insufficient local knowledge to navigate further south and round the mooring buoys, combined with the buoys not being lit, difficult to identify and located in a dark area of the Thames with back scatter from shore lights, the temptation to navigate directly towards the navigation lights of Victoria Rail Arch 2 is significant. 

Recommendations: The following recommendations have been issued to the PLA:

 • The PLA are recommended to produce lessons learnt from this report, for distribution to appropriate audiences. • The PLA are recommended to consider developing a Certificate of Compliance scheme dedicated to emergency vessels under Thames Byelaw 16 as not to hinder their operation.

 • The PLA is recommended to review its Memorandums of Understanding with the RNLI, Police, Fire Service and HM Coastguard. 

• The PLA is recommended to review the positioning of PLA Kirtling Barge Roads to establish if the moorings should be removed or lit.

 • The PLA is recommended to review unlit mooring buoys on the tidal Thames within high-speed zones, and identify the requirement for them to be lit based on similar traits of positioning and characteristics, including positioned on a bend in the river, positioned close to the edge of an authorised channel, poor back lighting conditions, and temptation for Masters to navigate on line of sight towards the buoy. 

• The PLA is recommended to produce a policy for the installation of moorings, piers and other works, in and adjacent to, the authorised channel. The following recommendations were issued to the vessel operator: 

• The vessel operator is recommended to ensure all Commanders, of all its stations on the Thames which operate and can be tasked to operate between Margaretness and Putney Bridge, hold a PLA LKE and maintain a regime of revalidation. 

• The vessel operator is recommended to ensure, for its stations on the Thames which operate and can be tasked to operate between Margaretness and Putney Bridge, that all crew members who intend to act as Helmsman and exceed the speed limits of Thames Byelaw 16, hold a PLA LKE. 

• The vessel operator is recommended to review the communications equipment used aboard their vessels which operate on the Thames above Margaretness, to ensure communications can be sufficiently heard whilst maintaining look out duties. 

• The vessel operator is recommended to review their training procedures for helms and commanders on the tidal Thames, to ensure that trainers always maintains navigational oversight and control of the vessel. The following recommendation is issued to all Emergency Service Operators: 

• Emergency service vessel operators are recommended to provide clear guidance to their Masters, ensuring they understand their legal obligations to maintain the safety of navigation and assess safe speed when responding to taskings and incidents.

Incident Description On 25 October 2022, an oil/chemical tanker departed from the berth in the early morning. While manoeuvring off the berth under pilotage, control of the ship was lost and it made contact with another fuel jetty at the site. The vessel’s starboard aft quarter was damaged in the accident, but there were no injuries. The resulting damage to the westernmost dolphin and a walkway, at the neighbouring berth caused the jetty to be taken out of commission for 2 months before being returned to service at reduced capacity until repairs were completed in September 2023. Contributing Factors:

 The investigation concluded that: 

• It was highly likely that the pilot was fatigued. 

• It was highly likely the pilot was unfamiliar with the berth. 

• The pilot had elected to sail without the support of a tug. 

• Port of London Authority documentation on tug use had not been comprehensively updated to include a mandatory tug requirement for the berth, which was subject to the Control of Major Accident Hazard Regulations 2015.

 • The vessel’s bridge team roles and responsibilities had not been allocated to best support the pilot during the manoeuvre. • The pre-departure master/pilot exchange was ineffective and unsuccessful, and challenges to decision-making did not result in changes to the departure plan. 

• Parts of the Port of London Authority’s marine safety management system lacked clarity, and the management of pilot fatigue did not identify and control the risk of fatigue.

 • The Port of London Authority had identified lessons from previous incidents, but these had not resulted in fully updated procedures and opportunities for capitalising on learning had therefore been lost. 

• The Port of London Authority has taken numerous actions as a result of this accident that have included revisions to its safety management system, the withdrawal of out-of-date guidance and the introduction of qualitative reviews of pilotage plans. Recommendations: Recommendations have been made to the Port of London Authority to: 

• Conduct risk assessments of high-risk berths (in conjunction with berth operators) • Review the risk and management of pilot fatigue 

• Implement stop procedures 

• Highlight to pilots the practices contained in the International Chamber of Shipping Bridge Procedures Guide. Recommendations have been made to the vessel operator to: 

• Revise its fleetwide training in Bridge Resource Management and review the use of aids to navigation during pilotage. The International Chamber of Shipping has also been recommended to:

 • Update its Bridge Procedures Guide regarding the assignment of roles and responsibilities during the master/pilot exchange.

Incident description

 On the 29th March 2021 A container vessel was approaching the berth ready to commence a swing, preparing to berth port side to alongside the terminal when the vessel continued on a south west trajectory and went aground on the opposing side of the channel. The vessel was able to re-float back into the navigational channel with the assistance of tugs and berth safely. No damage, pollution or injuries were caused. 

Actions Contributing factors 

There are a number of factors which contributed towards the incident. In summary these were determined to include: The lack of a passage plan; Vessels speed which caused distraction to the Pilot; Lack of monitoring vessels position; Inappropriate use of vessel engines, rudder and positioning of tugs; Lack of corrective measures when the swing did not go to plan; Bridge team management was not effective. 

All these factors contributed to the vessel coming to ground on the south side of the navigational channel, when there were no other mechanical or environmental reasons to affect the vessel. 

Recommendations on the PLA Pilot to undertake time in simulator followed by a practical trip with similar vessel characteristics with a senior pilot to enhance learning experience. 

Pilotage Manager to reissue updated version of OPL/2008/06 and re-word and reissue Operational letter OPL/2008/06 making clear the passage plan process during COVID restrictions. 

Harbour Masters to Review best practice and processes for swinging large vessels and are recommended to commence periodical audits of pilot passage plans of all classes to determine if fit for purpose. They are also recommended to develop procedures to include initial actions post serious incident. 

A copy of the investigation report should be circulated to all Pilots. 

Recommendations for tug operator 

Superintendent to ensure good positive communication is established & maintained between the Tug Master and Pilot to include confirmation of the securing positions & at all times during towage operations.

Actions taken by the VESSEL Onboard training to be conducted by Master for all bridge team members including lookout/helmsman. Training on “Roles/Responsibility of Bridge Team During Pilotage & Master/Pilot Relationship” to be conducted for all deck officers including Master. DPA to Re-iterate to fleet vessels the need to conduct detailed Master/Pilot Information Exchanges. DPA to share Incident report with entire fleet vessels for the lessons learnt.