Report on investigation into marine accident M/V Godafoss V2pm7 grounding in Løperen, Hvaler on 17 february 2011

The container vessel Godafoss ran aground at Kvernskjærgrunnen on 17 February 2011. The vessel was sailing with just one person on the bridge when the accident happened, despite the fact that the written shipboard procedures stated that the bridge should be manned by at least two persons. The investigation has shown that the shipping company's safety management system failed to identify this barrier breach.

The Accident Investigation Board Norway recommends that the shipping company revise its safety management system in order to ensure that its vessels are capable at all times of complying with the internal procedures for watchkeeping on the bridge and corresponding international requirements.

The container vessel Godafoss ran aground at Kvernskjærgrunnen on 17 February 2011 in compulsory pilotage waters without a pilot on board. The pilot instructions allowed for the pilot to disembark while the vessel was still in compulsory pilotage waters provided that this was deemed to be justifiable from a safety perspective. However, the criteria for assessing what was 'justifiable from a safety perspective' were not clear. The instructions therefore allowed for different interpretations and practices in relation to a pilot's duties in these waters. The investigation has also shown that the nonconformity reports that were submitted could have helped to improve procedures and common practice in the Norwegian Coastal Administration (NCA) had they been followed up in a satisfactory manner. However, the
nonconformity reports were not followed up to a satisfactory extent.

The Accident Investigation Board Norway recommends that the NCA follow up the handling of nonconformities in a satisfactory manner and ensure that all parties within its organisation with joint responsibility for safety at sea in a particular area have understood and accepted the applicable instructions and procedures.