Dutch Safety Board Calls For Stronger Risk Management After Fatal Shipyard Collision

The Dutch Safety Board (DSB) has concluded that risk management at Damen Shiprepair Rotterdam needs major improvements after an accident on February 21, 2024, led to the death of a worker.

The incident occurred when the crane vessel Saipem 7000 collided with the drilling platform Noble Regina Allen while docking at the Botlek shipyard.

The accident was caused by unfavourable weather conditions and other factors. A welder, who was working on scaffolding outside the drilling platform, became trapped in the collision and fell into the water.

Despite multiple search operations, his body was not found until more than three weeks later.

At 11:20 a.m., the Saipem 7000 was stable at the entrance of the dock, assisted by tugs on both the port (number 7) and starboard (number 4) sides, which were moving forward to slow down the vessel.

The bow of the crane vessel started drifting to port, toward the drilling platform at 11:21 a.m.

At 11:26:10 a.m., despite last-minute efforts to correct the vessel’s course by setting the rudder propellers to full starboard and ordering the starboard tugs to pull at full power, the Saipem 7000 collided with the Noble Regina Allen drilling platform.

The crane vessel was then detached from the platform and brought to a stable position in front of the dock entrance at 11:32 a.m.

The docking operation was immediately stopped upon realising that a person had fallen into the water.

The Dutch Safety Board found that risk management during complex operations at the shipyard needs improvement. The investigation highlights the need for better coordination, scenario planning, and communication between involved parties, especially when multiple activities occur simultaneously.

The shipyard must ensure that all risks are identified and controlled. All companies working together must discuss potential risk scenarios, hazards, and necessary actions before starting operations.

Key Recommendations from the Safety Board- The Safety Board recommends that Damen Shiprepair Rotterdam, the Regional Pilotage Corporation Rotterdam-Rijnmond, and Saipem work more closely together in future complex operations.

Improving Coordination and Communication

• All parties must hold pre-operation discussions to understand the entire work process.
• They should identify risks, consider various scenarios, and set up clear communication protocols.

Structured Risk Management for Simultaneous Operations

• Damen Shiprepair Rotterdam must develop a systematic risk management approach for operations occurring at the same time.
• All relevant parties should be involved in risk planning for both individual and combined projects.
• Different risk scenarios should be considered, and a documented approach must be followed.

Handling Deviations from Agreed Plans

• If any unexpected conditions arise, such as wind limits being exceeded, a joint reassessment of risks must be conducted.
• Adjustments to risk management plans should be made when necessary

Strengthening Life-Saving Measures

• Damen Shiprepair Rotterdam must update and improve its Life-Saving Rules based on the lessons learned from this incident.
• Employees should be actively involved in implementing safety measures.
• Safety must be considered as a shared responsibility

Pilotage Corporation’s Role and Responsibility- The Regional Pilotage Corporation Rotterdam-Rijnmond plays a key role in ensuring that pilots prepare well for complex docking operations. The Safety Board recommended the following improvements:

Regular Evaluation of Procedures:

• The pilot training manual (Vademecum) should be updated to ensure pilots have proper preparation guidelines for special transports.
• These procedures must be communicated to all pilots.

Better Preparation and Information Sharing:

• Pilots should have access to the latest information and use the most effective tools for safe navigation.
• They must ensure that all involved parties, including the shipyard and captain, are informed about risk assessments and decisions.

Team Coordination for Multi-Pilot Operations:

• When more than one pilot is involved in a transport operation, they must jointly prepare and execute the journey.
• They should be involved in planning at the same time and have access to the same information.
• Pilots should be able to challenge each other professionally on risk management decisions.

Saipem’s Responsibilities and Recommendations- The Safety Board recommended that Saipem, the owner of the crane vessel, take additional safety measures:

The captain, bridge team, and pilot(s) should make clear agreements about the docking process before the operation begins.

These agreements should include:

• Task distribution,
• Communication methods,
• Emergency scenarios, and
• Steps to handle uncertainties during operations.
• Saipem must also check whether the shipyard has identified all risks of complex operations before docking.

Reference: onderzoeksraad

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