UK Marine Accident Investigation Branch (MAIB) has issued an investigation report into the incident of contact of chemical tanker Ali Ka with Oikos Jetty 2 on the River Thames at Canvey Island, England on 25 October 2022.
The incident
On 25 October 2022, the 129.5m oil/chemical tanker Ali Ka departed from the Oikos fuel storage facility, Canvey Island, Essex 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. Ali Ka’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 Oikos Jetty 2 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. The investigation concluded that it was highly likely that the pilot was fatigued, was unfamiliar with the berth, and had elected to sail without the support of a tug. It also concluded:
- The Port of London Authority documentation on tug use had not been comprehensively updated to include a mandatory tug requirement for the Oikos berth, which was subject to the Control of Major Accident Hazard Regulations 2015.
- Ali Ka’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 capitalizing on learning had therefore been lost.
How fatigue impacts decision making
Based on the sleep, wake, and work history of the pilot, it is highly likely that the pilot was experiencing an elevated level of fatigue, with the average SAFTEFAST predicted scores falling in ranges classified as high or severe fatigue at the time of the accident. Behaviors and performance changes consistent with fatigue were further explored through on-board transcripts and data collected during Critical Decision Making (CDM) interviews.
When individuals experience sleep loss and heightened fatigue, common behavioral and performance changes occur due to the impacts of sleep deprivation. Reviewing the on-board transcript revealed the following behaviors and performance changes consistent with fatigue:
- Tunnel vision focused on water depth and distance from the Oikos 1 jetty, while overlooking the proximity of the Oikos 2 dolphin.
- Conversations that were uni-dimensional, centered on the plan, time, and tide levels.
- Potentially reduced perception of risk regarding the assistance a tug could provide and its balance with risks from decreasing water levels.
- Decreased clarity in communication.
- Short and abrupt interactions with others, primarily the Master.
- Possible forgetfulness, such as not returning the radio channel, leading to missed calls from VTS later.
While these behaviors align with fatigue, other factors such as the pilot’s personality, stress, or lack of recent experience on this berth could also contribute. However, fatigue exacerbates predispositions to issues like poor communication and impairs the ability to regulate behavior.
From the CDM interview and the MAIB’s summary of the VDR review, additional behaviors consistent with fatigue were noted, including:
- Delayed responses from the pilot on the bridge.
- Potential loss of situational awareness regarding the position of the Oikos 2 dolphin, coupled with incomplete sharing of the mental model with the Master.
- Narrow focus on tide levels and time of day.
These findings underscore the critical impact of fatigue on decision-making and operational safety, highlighting the need for effective fatigue management strategies in maritime operations.
Key conclusions on safety issues include:
-
Control of Ali Ka was lost, resulting in the ship making contact with Oikos 2 because the plan for the departure manoeuvre missed key information and was compromised by incoherencies in PLA documentation.
-
Ali Ka’s BRM and training did not result in the master or bridge team issuing effective challenges to the pilot’s plan.
-
PLA’s stop procedure was ineffective at dealing with clear challenges to the plan and did not help to prevent this accident.
-
Previous accidents were not recognised as warnings and risk controls were not reappraised in time to inform the approaches employed for Ali Ka, for example in tug provision.
-
PLA’s management of the allocation and monitoring of pilots did not sufficiently control the fatigue risk.
-
The risk management processes of PLA and Oikos Storage Limited did not combine to mitigate the risk of contact with shore infrastructure at Oikos 2, which was a COMAH site.
-
The suboptimal calculation, and depiction in the ECDIS, of safety contour values left all exposed to unappreciated risk. This lack of risk appreciation by the ship’s bridge team meant that pilot A was not well supported during the departure manoeuvres.
-
The pilot passage plan did not deliver a safe departure from harbour for Ali Ka.
-
Components of PLA’s marine SMS were not current, hard to access, and in some cases contradictory, and this did not support the generation of a safe pilot passage plan.
-
PLA’s management had identified safety lessons from previous accidents and also from navigational risk assessments, but these lessons had not wholly persisted and has not led to lasting improvements to PLA’s marine SMS.
- Roles and responsibilities of bridge teams are not included in the ICS Bridge Procedures Guide’s MPX checklists.
