UK MAIB released its accident investigation report into the grounding of the chemical tanker Key Bora at Kyleakin Pier, Isle of Skye, Scotland.
The incident
At 1505 on 28 March 2020, the Gibraltar registered chemical tanker Key Bora ran aground at Kyleakin pier, Isle of Skye, Scotland. Key Bora’s hull was holed by the grounding and foodwater entered empty ballast tanks; there was no injury or pollution.
Key Bora was approaching Kyleakin pier, and the master was conning from the starboard bridge wing console. This was the first time that the vessel and the master had arrived at this pier and the berthing had been planned to coincide with low water, when slack tidal stream was expected.
When Key Bora was very close to the pier, it ran aground on a charted 4.9m obstruction. After 12 minutes aground, Key Bora foated free and was berthed using its own power. Key Bora ran aground because its passage plan had been based on inaccurate information, including a dredge survey that did not show the charted hazard where the vessel grounded, and misleading tidal stream information.
Additionally, the vessel’s electronic chart display and information system had not been used effectively by the crew to warn of danger ahead.
The investigation also identifed significant weaknesses in the safety management of the Kyleakin pier, owned and operated by the aquaculture company Mowi Scotland Limited. This included that the site was not being operated in accordance with the Port Marine Safety Code, and there was no marine safety management system.
Mowi Scotland Limited had cited both items as risk mitigation measures in its application to Marine Scotland to build the pier; however, these measures had not been implemented before operations commenced. This happened because there was no process in place to ensure that risk mitigation measures, described in the licence application, were in place before operations commenced.
Since the accident, Marine Scotland has added a standard condition to all marine licences requiring licensees to carry out the licensable activity in accordance with the licence, the application, and all plans and programmes submitted as part of the application.
LESSONS TO BE LEARNED
Safety issues directly contributing to the accident
1. Key Bora ran aground primarily because the passage plan for the approach to the pier was based on inaccurate survey data.
2. Although not intended for navigation, the dredge survey data was prioritised on board Key Bora ahead of the more accurate ENC information because it had been received from an apparently reliable source and appeared to be accurate, authentic and timely.
3. Key Bora’s arrival was arranged to coincide with a time when slack tidal stream was expected; this decision was also based on unintentionally misleading pre-arrival information provided by the agent.
4. Despite indications that conditions were not as expected, no action was taken to abort the passage.
5. Key Bora’s bridge team did not adhere to the principles of BRM, which probably increased the navigational risk.
6. ECDIS, which was Key Bora’s primary means of navigation, was not used efectively to support safe navigation or warn of danger.
7. The master did not inform the company that Key Bora was arriving at Kyleakin for the frst time or that there was a confict between the pre-arrival navigation information and that shown on the ENC. This almost certainly happened because the master underestimated the cumulative navigational risks associated with the arrival at Kyleakin.
Safety Issues NOT directly contributing to the accident
1. The boulder obstruction where Key Bora grounded was almost certainly left over from the 2018 dredging operations, MBES surveys of the area were not intended to be used for navigation, and it lay outside the area contracted for dredging.
2. The Kyleakin pier was not being operated in accordance with a MSMS or the PMSC, both of which had featured as risk mitigation measures in the licence approval process. This happened because there was no process to assure that agreed mitigation measures were in place prior to operations commencing.
3. Analysis of harbours managing similar levels of risk indicated that a Harbour Empowerment Order would be appropriate in Kyelakin but this was not considered during the planning/licensing process.
4. Contrary to the assumption on board Key Bora, the evidence in this case demonstrated the efectiveness of the MCA and UKHO civil hydrography programme to deliver timely and accurate survey data.
5. Reliance on the crew to conduct navigational audits of their own processes was suboptimal in providing company level assurance of safe onboard practices.
Recommendations
Mowi Scotland Limited is recommended to:
- Ensure that marine operations at Kyleakin follow the guidance in the Port Marine Safety Code and its associated Guide to Good Practice.
- Consider applying for a Harbour Empowerment Order in order to establish a statutory harbour authority, delivering the associated maritime safety benefts, at Kyleakin.