Report on incident with HNoMS Thor Heyerdahl with loss of power supply and propulsion on 6 August 2022 at Haakonsvern
Defence report 2023/02
On 6 August 2022, HNoMS Thor Heyerdahl docked at Haakonsvern's main quay to carry out planned maintenance. A hawser entered the frigate’s bow thruster and triggered a series of events that resulted in the vessel losing both propulsion and power for a while. The report is now ready and comes with three recommendations to the Ministry of Defence. The Norwegian Safety Investigation Authorithy advises the Ministry of Defense to ensure a comprehensive and independent supervisory function for naval activities in the defence sector, to ensure that measures are implemented to ensure that the frigates' manning concept is made robust enough for safe operation, and that measures are implemented to ensure that the operational responsible of the frigates has an overview of the overall risk picture that affects safe operation.
The NSIA points out that this incident and the previous incident with the frigate HNoMS Helge Ingstad have several similarities, and will give the Ministry of Defence as the superior authority a safety recommendation related to the manning concept of the Norwegian Navy's frigates. Safety recommendations given to the Norwegian Navy in this area in connection with the report on HNoMS Helge Ingstad has not been sufficiently followed up and closed. The NSIA believes that the safety problem was also a contributing factor in this incident and is therefore putting forward the safety recommendation to the Ministry of Defence as overall responsible for ship safety.
The systems for keeping track of the technical condition of the vessels were not sufficient to give a correct picture of the risk the vessel was sailing with. The way this worked, it was not possible to summarize the overall technical condition of the navy's individual vessels. It was the individual CO's responsibility to decide whether the vessel was safe to sail, without it being possible in practice for the captain to get a complete overview of the condition of the vessel and what consequences the loss of several seemingly less important components would have taken together.
Today's organisation in the defence sector does not have mechanisms that are able to uncover and correct systemic safety issues related to the safe operation of vessels. In this investigation, the NSIA has also revealed a need for a comprehensive and independent supervisory authority. Since the Ministry of Defence has not given feedback on previously issued safety recommendations, the message is reinforced by repeating an already issued safety recommendation.
Published 17.03.2023
Safety recommendation
Safety recommendation Defence no 2023/04T
On 6 August 2022, HNoMS Thor Heyerdahl arrived at the main quay of Haakonsvern Naval Base for planned maintenance. A hawser entered the frigate’s bow thruster and triggered a series of events that resulted in the vessel losing both propulsion and power for a while.
The investigation has shown that the frigate’s crew did not comply with key requirements in the Royal Norwegian Navy’s crewing concept. In connection with this incident, neither the crew nor the Navy had sufficient overview of how the complete absence of key personnel could affect the crew’s action competence during a critical safety incident. This constituted a vulnerability in relation to safe operation of the vessels and compromised the Navy’s ability to produce combat-ready units.
The Norwegian Safety Investigation Authority recommends that the Ministry of Defence ensure that the Norwegian Armed Forces implement measures to ensure that the frigate’s crewing concept is sufficiently robust to ensure safe operation.
Safety recommendation Defence no 2023/05T
On 6 August 2022, HNoMS Thor Heyerdahl arrived at the main quay of Haakonsvern Naval Base for planned maintenance. A hawser entered the frigate’s bow thruster and triggered a series of events that resulted in the vessel losing both propulsion and power for a while.
The investigation has shown that neither the Navy nor the Norwegian Defence Materiel Agency had sufficient knowledge about the implications of known technical fault conditions or nonconformities for the safe operation of the frigates. Consequently, the Navy operated the frigates without being aware of the total risk under which they were sailing. Several of the fault conditions and nonconformities had a direct impact on the sequence of events.
The Norwegian Safety Investigation Authority recommends that the Ministry of Defence ensure that the Norwegian Armed Forces, in cooperation with the Norwegian Defence Material Agency, implement measures to ensure that the frigate operator is aware of the overall risk situation with a bearing on safe operation.
Safety recommendation Defence no 2023/06T
On 6 August 2022, HNoMS Thor Heyerdahl arrived at the main quay of Haakonsvern Naval Base for planned maintenance. A hawser entered the frigate’s bow thruster and triggered a series of events that resulted in the vessel losing both propulsion and power for a while.
Both the present investigation and previous ones have shown that the scheme for supervision of naval activities in the defence sector appears to be inadequately organised. It does not adequately fulfil the purpose of a comprehensive, independent supervisory scheme. The Norwegian Safety Investigation Authority considers this to be unfortunate and believes that it may have had an impact on the safety of naval operations in the defence sector.
The Norwegian Safety Investigation Authority recommends that the Ministry of Defence implement measures to ensure a comprehensive and independent supervisory function for naval operations in the defence sector.
Facts
| Location | At Haakonsvern, Bergen |
| Occurrence date | 06.08.2022 |
| Category of Occurrence | Incident |
| Defence branch | Royal Norwegian Navy |