Issued November 2019

REPORT Marine 2019/08

PART ONE REPORT ON THE COLLISION ON

8 NOVEMBER 2018 BETWEEN THE FRIGATE
HNOMS HELGE INGSTAD AND THE OIL TANKER
SOLA TS OUTSIDE THE STURE TERMINAL IN THE
HJELTEFJORD IN HORDALAND COUNTY

AIBN and DAIBN has compiled this report for the sole purpose of improving safety at sea. The object of a
safety investigation is to clarify the sequence of events and root cause factors, study matters of significance
for the prevention of maritime accidents and improvement of safety at sea, and to publish a report with
eventually safety recommendations. The Board shall not apportion any blame or liability. Use of this report for
any other purpose than for improvements of the safety at sea shall be avoided.

Accident Investigation Board Norway • P.O. Box 213, N-2001 Lillestrøm, Norway • Phone: + 47 63 89 63 00 • Fax: + 47 63 89 63 01
www.aibn.no • [email protected]
This report has been translated into English and published by the Accident Investigation Board Norway (AIBN) to facilitate access by
international readers. As accurate as the translation might be, the original Norwegian text takes precedence as the report of reference.

Photo of ferry on the Norwegian west coast: Bente Amandussen

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INTRODUCTION TO THE PART ONE REPORT

This part one report1 contains the results of the Accident Investigation Boards Norway’s
investigation of the sequence of events up until the time when the collision occurred. Information
relating to the sequence of events after the collision, will be included in the part two report.

The further investigation will focus on how the accident developed after the collision, up until the
time when all crew had been evacuated and the frigate was deemed to have been lost. However, we
cannot exclude the possibility that need to revise some parts of this part one report may arise when
further information is collected and further analyses are conducted.

As a result of the scope and complexity of the investigation, it is not possible to estimate a date of
completion for the part two report. The investigation will continue at a high level of activity.

1
The report is published within 12 months of the accident in order to present the results of the investigation so far and
to give the parties involved and the public an update on the status of the investigation. This is in accordance with the
Act of 24 June 1994 No 39 (the Norwegian Maritime Code) Section 485 fifth paragraph.

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TABLE OF CONTENTS

NOTIFICATION OF THE ACCIDENT ............................................................................................. 5

SUMMARY ......................................................................................................................................... 6

1. FACTUAL INFORMATION .............................................................................................. 8

1.1 Introduction .......................................................................................................................... 8
1.2 Sequence of events ............................................................................................................... 9
1.3 The rescue operation .......................................................................................................... 28
1.4 Description of injuries/damage .......................................................................................... 29
1.5 Weather and sea conditions ............................................................................................... 30
1.6 The Hjeltefjord and the traffic situation............................................................................. 31
1.7 Automatic Identification System (AIS) ............................................................................. 33
1.8 Personnel information ........................................................................................................ 35
1.9 The frigate HNoMS Helge Ingstad .................................................................................... 42
1.10 The oil tanker Sola TS ....................................................................................................... 56
1.11 The Norwegian Navy ......................................................................................................... 60
1.12 The shipping company Tsakos Columbia Shipmanagement (TCM) S.A.......................... 71
1.13 The Norwegian Coastal Administration (NCA), VTS centres and pilot services ............. 74
1.14 Medical an personal considerations ................................................................................... 85
1.15 Special investigations......................................................................................................... 87
1.16 Other information............................................................................................................... 94
1.17 Implemented measures....................................................................................................... 95

2. ANALYSIS ........................................................................................................................ 99
2.1 Introduction ........................................................................................................................ 99
2.2 Assessment of the sequence of events ............................................................................. 101
2.3 The frigate HNoMS Helge Ingstad and the Navy ............................................................ 111
2.4 The tanker Sola TS with the pilot and the shipping company Tsakos Columbia
Shipmanagement S.A. ...................................................................................................... 132
2.5 Fedje VTS and the Norwegian Coastal Administration (NCA) ...................................... 136

3. CONCLUSION ................................................................................................................ 142

3.1 Introduction ...................................................................................................................... 142
3.2 The sequence of events, operational and technical factors .............................................. 142
3.3 Organisational and systemic factors ................................................................................ 145

4. SAFETY RECOMMENDATIONS ................................................................................. 148

5. FURTHER INVESTIGATIONS ..................................................................................... 152

DETAILS OF THE VESSELS AND THE ACCIDENT................................................................. 153

REFERENCES................................................................................................................................. 154

ABBREVIATIONS ......................................................................................................................... 155

APPENDICES ................................................................................................................................. 157

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NOTIFICATION OF THE ACCIDENT

On the morning of Thursday 8 November 2018, the Accident Investigation Board Norway (AIBN)
was informed that the frigate HNoMS Helge Ingstad and the Maltese-registered tanker Sola TS had
collided outside the Sture Terminal in Øygarden municipality in Hordaland county (see Figure 1).
The AIBN contacted the Defence Accident Investigation Board Norway (DAIBN) and it was
decided to initiate a joint investigation into the accident, led by the AIBN. In the course of the
afternoon and evening of 8 November 2018, 14 representatives of the AIBN and the DAIBN arrived
in Bergen to initiate the investigation.

The investigation was conducted in accordance with the Act of 24 June 1994 No 39 (the Norwegian
Maritime Code) Chapter 18. The Marine Safety Investigation Unit of Malta and the Spanish
Standing Commission for Maritime Accident and Incident Investigations (CIAIM) have also
participated in the investigation as ‘substantially interested states’; see Section 474 of the
Norwegian Maritime Code.

Hereinafter the investigation authorities (the AIBN and the DAIBN) are referred to as the AIB.

Figure 1: The vessels collided outside the Sture Terminal in the Hjeltefjord. Map: The NCA/AIBN

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SUMMARY

The frigate HNoMS Helge Ingstad and the tanker Sola TS collided in the Hjeltefjord in the early
hours of 8 November 2018. The frigate had 137 persons on board with a mix of conscripts and
permanent crew. A total of seven watchstanding personnel were present on the bridge, including
two trainees. The tanker Sola TS was operated by the Greek shipping company Tsakos Columbia
Shipmanagement (TCM) S.A. There was a total of 24 persons on board. The bridge was manned by
four persons, including the pilot.

HNoMS Helge Ingstad sailed south at a speed of approximately 17–18 knots with the automatic
identification system (AIS) in passive mode, i.e. no transmission of AIS-signal. The frigate’s bridge
team had notified Fedje Vessel Traffic Service (VTS) of entering the area and followed the reported
voyage. Sola TS had been loaded with crude oil at the Sture Terminal, and notified Fedje VTS of
departure from the terminal. Sola TS exhibited navigation lights. In addition some of the deck lights
were turned on to light up the deck for the crew who were securing equipment etc. for the passage.

In advance of the collision, Fedje VTS had not followed the frigate’s passage south through the
Hjeltefjord. The crew and pilot on Sola TS had observed HNoMS Helge Ingstad and tried to warn
of the danger and prevent a collision. The crew on HNoMS Helge Ingstad did not realise that they
were on collision course until it was too late.

At 04:01:15, HNoMS Helge Ingstad collided with the tanker Sola TS. The first point of impact was
Sola TS’ starboard anchor and the area just in front of HNoMS Helge Ingstad’s starboard torpedo
magazine.

HNoMS Helge Ingstad suffered extensive damage along the starboard side. Seven crew members
sustained minor physical injuries. Sola TS received minor damages and none of the crew were
injured. Marine gas oil leaked out into the Hjeltefjord. The Institute of Marine Research has
ascertained the effect of the oil spill had little impact on the marine environment.

The AIBN’s investigation has shown that the situation in the Hjeltefjord was made possible by a
number of operational, technical, organisational and systemic factors:

- As a consequence of the clearance process, the career ladder for fleet officers in the Navy and
the shortage of qualified navigators to man the frigates, officers of the watch had been granted
clearance sooner, had a lower level of experience and had less time as officer of the watch than
used to be the case. This had also resulted in inexperienced officers of the watch being assigned
responsibility for training. Furthermore, several aspects of the bridge service were not adequately
described or standardised. The night of the accident, it turned out, among other things, that the
bridge team on HNoMS Helge Ingstad did not manage to utilise the team’s human and technical
resources to detect, while there was still time, that what they thought was a stationary object
giving off the strong lights, in fact was a vessel on collision course. Organisation, leadership and
teamwork on the bridge were not expedient during the period leading up to the collision. In
combination with the officer of the watch’s limited experience, the training being conducted for
two watchstanding functions on the bridge reduced the bridge team’s capacity to address the
overall traffic situation. Based on a firmly lodged situational awareness that the ‘object’ was
stationary and that the passage was under control, little use was made of the radar and AIS to
monitor the fairway.

- When Sola TS set out on its northbound passage with the forward-pointing deck lights turned on,
it was difficult for the frigate’s bridge team to see the tanker’s navigation lights and the flashing
of the Aldis lamp, and thereby identify the ‘object’ as a vessel. The shipping company Tsakos

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Columbia Shipmanagement SA had not established compensatory safety measures with regards
to the reduction of the visibility of the navigation lights due to deck lighting. Furthermore, radar
plotting and communication on the bridge did not sufficiently ensure the effect of active
teamwork to build a common situational awareness. This could have increased the time window
for identification and warning of the frigate.

- The Norwegian Coastal Administration (NCA) had not established human, technical and
organisational barriers to ensure adequate traffic monitoring. The functionality of the monitoring
system with regards to automatic plotting, warning and alarm functions, was not sufficiently
adapted to the execution of the vessel traffic service. Lack of monitoring meant that the VTS
operator’s situational awareness and overview of the VTS area were inadequate. Hence, Fedje
VTS did not provide the vessels involved with relevant and timely information and did not
organise the traffic to ensure the tanker’s safe departure from the Sture Terminal.

- On the southbound voyage, HNoMS Helge Ingstad sailed with AIS in passive mode. This meant
that the frigate could not be immediately identified on the screens at Fedje VTS or Sola TS.
None of the parties involved made sufficient use of available technical aids. It was a challenge
for maritime safety that the Navy could operate without AIS transmission and without
compensatory safety measures within a traffic system where the other players largely used AIS
as their primary (and to some extent only) source of information.

The Accident Investigation Board Norway submits a total of 15 safety recommendations based on
the investigation of the sequence of events leading up to the collision.

Information and any safety recommendations relating to the sequence of events after the collision
up until the time that the frigate ran aground and sank, will be included in the part two report.

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1. FACTUAL INFORMATION
1.1 Introduction

The description of the sequence of events is based on interviews with members of both
vessel crews, the pilot and the Vessel Traffic Service (VTS) operators who were on duty
during the night of the accident, in addition to technical/electronic information obtained
from both vessels, Fedje VTS Centre, the Joint Rescue Coordination Centre’s action log,
the log from the Norwegian Coastal Administration’s (NCA) automatic identification
system (AIS), and radio and radar recordings from Fedje VTS.

The AIBN has furthermore conducted technical examinations on board HNoMS Helge
Ingstad and carried out an observation voyage with one of the frigate’s sister ship and
Sola TS. A significant amount of information has also been obtained from the Norwegian
Maritime Authority, the NCA, the police, the Royal Norwegian Navy, the Norwegian
Defence Material Agency (NDMA) and Tsakos Columbia Shipmanagement S.A.

The AIBN has also used external consultants for input relating to human factors,
situational awareness and military navigation, and for eyesight testing of the bridge crew
on HNoMS Helge Ingstad.

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1.2 Sequence of events

1.2.1 Sequence of events in the initial phase (00:00–03:40)

1.2.1.1 HNoMS Helge Ingstad

During the night leading up to Thursday 8 November 2018, HNoMS Helge Ingstad was
on a southbound voyage from Måløy in Sogn og Fjordane county towards Sletta north of
Haugesund (see Figure 2).

Figure 2: The Hjeltefjord is marked with a black circle. The red line shows the planned route of
HNoMS Helge Ingstad through the area from the Krakhellesundet sound in the north. The shaded
area shows the Fedje VTS area. Map: NCA/Royal Norwegian Navy/AIBN

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The frigate’s participation in the NATO2 exercise Trident Juncture 2018 had ended on
Wednesday 7 November. The plan was to reach destination at Dundee in Scotland on
Friday 9 November, and the voyage was being used for crew training in inshore
navigation. The automatic identification system (AIS) was mostly3 in receive mode
(receive only, no transmission of own AIS information; see sections 1.7 and 1.9.3.7), and
the frigate’s navigation lights were on (two masthead lights, stern light and sidelights).

The bridge was manned as shown in Figure 3. The officer of the watch (OOW) was
responsible for navigation of the frigate. There were another six crew on the bridge
during the voyage: an officer of the watch trainee (OOWT), an officer of the watch
assistant (OOWA), an officer of the watch assistant trainee (OOWAT) and a bridge
watch team consisting of three conscripts rotating between the functions of helmsman
(HM), port lookout (PORT LO) and starboard lookout (STBD LO) (for further details,
see section 1.8.1). The training of the OOWT/OOWAT focused on checking the frigate’s
position on the electronic chart display (ECDIS4) using optical navigation aids.

Figure 3: Positions on the bridge of HNoMS Helge Ingstad. Illustration: The Royal Norwegian
Navy/AIBN

The OOW on the 00–04 watch arrived on the bridge at around 23:40 on Wednesday 7
November and completed the handover procedure with the officer being relieved (20–24
watch). The frigate was a little way north of Florø at the time. The OOWT had been on
duty since around 20:00 and was to continue to navigate until the frigate was south of
Krakhellesundet.

During the southbound voyage, the Commanding Officer (CO) was present on the bridge
when they sailed through areas of maritime traffic or narrow fairways. The CO made a
final appearance on the bridge at approximately 01:30 on Thursday 8 November, before
the frigate entered Krakhellesundet. At around 02:00, after passing through
2
NATO – North Atlantic Treaty Organization – military alliance of 29 countries in Europe and North-America.
3
On this particular voyage, HNoMS Helge Ingstad had last transmitted AIS information when passing through
Skatestraumen in the evening before the accident.
4
ECDIS – electronic chart display and information system that meets requirements set by the International Maritime
Organization (IMO).

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Krakhellesundet, the CO reminded the OOW to call Fedje Vessel Traffic Service (VTS)
before reaching the northern boundary of the Fedje VTS area at Sognoksen. They were
also told to wake up the executive officer (XO) when they reached the southern end of
the Hjeltefjord, so that he could be present on the bridge when passing Bergen and
through the Vatlestraumen straits. The CO then left the bridge.

At 02:00, the bridge watch team was relieved along with the OOWAT. A new bridge
watch team arrived, and the starboard and port lookouts and helmsman were relieved.
The relieving OOWAT arrived and went through the handover procedure with the
OOWAT being relieved. The relieving OOWAT then took over the watch together with
the OOWA on the 00–04 watch.

The plan was for the relieving OOWT to go on watch after they had sailed through
Krakhellesundet and navigate the frigate from Sognesjøen to the southern end of the
Hjeltefjord. The relieving OOWT arrived on the bridge at 02:18 and went through the
handover procedure with the OOWT being relieved. The OOWT being relieved logged
the watch change at 02:24 in the log book.

The OOW navigated the frigate while the relieving OOWT established night vision and
got ready to navigate. As they continued south, the OOWT navigated the frigate and also
performed course changes by issuing orders to the HM. The OOW oversaw the
navigation (see section 1.8.1.3).

At 02:38, HNoMS Helge Ingstad was directly south of Ytre Steinsund, approximately 4
nautical miles (nm) north-east of the boundary of the Fedje VTS area (see Figure 4).

Figure 4: Screenshot of radar replay from Fedje VTS showing the position of HNoMS Helge
Ingstad at 02:38 and 02:50, respectively. The broken line represents the boundary of the Fedje
VTS area. Note: When preparing the radar replay after the accident, an artificially long afterglow
was used to illustrate the frigate’s voyage. Source: The NCA/AIBN

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At 02.38, the OOW called Fedje VTS by mobile phone, with the information that they
would enter the VTS area from the north. The OOW informed the VTS of the frigate’s
planned voyage route through the VTS area: the Holmengrå fairway, south through the
Hjeltefjord and Vatlestraumen, leaving the area at Eldjarnet in the south.

In addition to VHF channel 165, HNoMS Helge Ingstad also established a listening watch
on VHF channel 80, the VTS’s working frequency for the area. The OOW had the
responsibility for maintaining a listening watch (see chapter 1.13.2.2). The frigate sailed
on at a speed of between 17 and 18 knots, which was normal transit speed when sailing
with both diesel engines in ‘cruise’ mode.

The Fedje VTS operator (Area North), who was responsible for the area north of Jona
light, confirmed receipt and logged the message in the VTS’s log-keeping system at
02:40. The VTS operator saw a radar echo on the overview screen (see section 1.13.3.3)
that was assumed to be the naval vessel.

At 02:50, HNoMS Helge Ingstad entered the Fedje VTS area from the north (see Figure
4). The VTS operator did not plot the vessel’s movements on the radar. The VTS
operator would normally, as a matter of routine, plot vessels when they passed into the
traffic area, but did not do so this time. Because HNoMS Helge Ingstad was not
transmitting AIS signals, information about the vessel’s identity, course and speed
vectors was also not transmitted automatically.

1.2.1.2 Sola TS

On Wednesday 7 November, the oil tanker Sola TS had been loaded with crude oil at the
Sture Terminal, an oil and gas terminal in Øygarden municipality in Hordaland county. In
the early hours of Thursday 8 November, Sola TS was getting ready to depart. The tanker
was to be assisted by a pilot, and at 01:20 the pilot received the assignment to assist Sola
TS on departure from the Sture Terminal.

The pilot boarded Sola TS at approximately 02:50, about the same time as HNoMS Helge
Ingstad entered the Fedje VTS area from the north. The pilot and master completed the
‘master-pilot exchange’ (MPX), which consisted of exchanging information about the
voyage route, ship particulars, weather and local conditions (see section 1.12.2.4). It was
also agreed that the pilot would communicate with the tugboats and the VTS centre in
Norwegian, but that the pilot would communicate all information of material importance
to the master in English.

Just before 03:00, the master turned off the aft-pointing deck lights on Sola TS, while
keeping the forward-pointing deck lights on to provide light for the work of clearing the
forward deck. The two tugboats Ajax and Tenax arrived at Sola TS soon afterwards.
Figure 5 shows the positions of Sola TS and HNoMS Helge Ingstad at 03:00.

At 03:05, the bridge on Sola TS was manned by the pilot, the master and the navigation
officer on watch. The navigation instruments had been switched on and tested before the
pilot arrived on board. The tanker’s radars were switched on when the pilot confirmed
that this could be done.

5
International distress frequency.

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At 03:12, the pilot on board Sola TS had established contact with the tugboats. Sola TS
lay starboard side alongside the quay. The tugboat Ajax took up position midship on the
port side, while Tenax was getting ready to pass its tow line through the stern centre lead
on Sola TS (see Figure 6).

Figure 5: At 03:00, Sola TS (blue dot) lay alongside at the Sture Terminal, while HNoMS Helge
Ingstad (red dot) was approx. 17 nm north of the Sture Terminal. Map: NCA/AIBN

Sola TS

Figure 6: The situation around Sola TS at 03:13, when the pilot informed Fedje VTS that they
were ready to take in the mooring lines at the Sture Terminal. Illustration: AIBN

At 03:13, the pilot on board Sola TS called Fedje VTS on VHF channel 80 with the
message that they were starting to take in the mooring lines and preparing to depart from
the Sture Terminal. The VTS operator monitoring the area north of Jona light was
downstairs getting some food at the time, so it was the VTS operator monitoring the

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southern area who confirmed receipt of the pilot’s message. The Area North VTS
operator returned shortly afterwards and was informed of this by the other operator. It
was the Area North VTS operator who answered the subsequent VHF calls from vessels
in the area north of Jona light.

Figure 7 shows the traffic situation in the Hjeltefjord at 03:13.

Figure 7: The traffic situation in the Hjeltefjord when HNoMS Helge Ingstad had passed
Holmengrå (at 0313). There were one southbound and two northbound vessels in the area east
of Fedje. There was one passing vessel by the Sture terminal, where Sola TS still was docked.
Illustration: AIBN

At 03:13, none of the radars or the ECDIS on Sola TS were scaled to display the areas of
maritime traffic to the north and south (see Figure 8). At 03:27, approximately 10
minutes before departure, the S-band radar was set to 3 nm and the X-band radar to 1.5
nm. There was still no indication of other vessel traffic on the radar displays, other than
one southbound vessel (‘Stril Herkules’) that was just passing the Sture Terminal. See
section 1.10.3.2 for a more detailed description.

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Figure 8: The S-band radar on Sola TS, set to a range scale of 0.75 nm, showed no other
maritime traffic at 03:13. Source: Tsakos Columbia Shipmanagement S.A.

After reporting to Fedje VTS that they were taking in the moorings, the pilot and master
went out on the starboard bridge wing to oversee the departure. As normal, the pilot was
given the con of the vessel, while the master maintained command and monitored the
actions of the pilot, the manoeuvring and navigation. There was a display on the bridge
wing console that could be set to display either ECDIS or radar. Together with the view
from the bridge wing, this enabled the pilot and the master to monitor the traffic in the
nearby area. The bridge wing also had a VHF radio that enabled the pilot and master to
also monitor radio communication. After the accident, it has not been possible to verify
what was displayed on the bridge wing display or whether the VHF radio was set to the
VTS centre’s channel. The pilot has explained that visibility was good, so that they were
able to keep an eye on the traffic situation around the ship.

The navigation officer on watch and the helmsman remained inside the bridge on Sola TS
and could monitor traffic by radar and ECDIS. They could also listen in on any
communication with the VTS as long as the communication was in English.

Sola TS continued to prepare for departure. At 03:24, Tenax was made fast at the stern.
At 03:36, all mooring lines had been retrieved, and Ajax, which had taken up position on
the starboard side of Sola TS, started to push Sola TS from the quay. The pilot ordered
slow speed ahead and they started manoeuvring away from the quay. The manoeuvring
started with the aft tugboat pulling sideways towards the tanker’s port side at the same
time as the forward tugboat pushed on the starboard side.

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1.2.2 Sequence of events from 03:40 to 03:57

1.2.2.1 HNoMS Helge Ingstad

At 03:40, HNoMS Helge Ingstad was approximately 7 nm north of the Sture Terminal in
the Hjeltefjord, still moving at a speed of between 17 and 18 knots. The OOW of the
04–08 watch arrived on the bridge to prepare for the onward voyage. The OOW first
went into the chartroom at the aft end of the bridge to check the frigate’s position and the
voyage route. From 03:45 to 03:53, the relieving OOW and the OOW being relieved
went through the handover procedure on the bridge. The OOWT was still navigating the
vessel and did not take active part in the handover. The OOW being relieved was
responsible for navigation of the frigate in this period.

The OOW being relieved informed the relieving OOW about what they had been doing
on the watch, how the two OOWTs had performed and of the plans for the voyage during
the hours ahead. The OOW being relieved pointed out that the XO was to be woken in
approximately 30 minutes, about the time they would pass Jona light, at which time the
OOWT would also be relieved. They talked about forecast weather conditions with rising
winds and increasing wave heights into the day, and reviewed the bridge system, radar
and communication settings.

The OOWs also discussed the traffic in the fairway. On the port side of the frigate’s
course line, three northbound vessels were approaching. These were acquired6 on the
frigate’s radar along with one vessel heading in the same direction as the frigate. The
navigation officers also discussed a stationary object at or near the Sture Terminal, which
was giving off a great deal of light to starboard of the frigate’s course line. The two
OOWs stood around the radar (MFD7 1; see Figure 3) and discussed whether the ‘object’
could be the terminal’s quay, or possibly a fish farm or rig/platform. The OOWs have
stated that the ‘object’ transmitted AIS signals, but no speed vector, and that they
assumed that it was stationary. The ‘object’ was therefore not tracked on the frigate’s
radar. The OOWs’ statements differ somewhat: The OOW being relieved had observed
two AIS signals and pressed one of them and read ‘Sola TS’. The relieving OOW had
seen a blue mark and interpreted this to be an AIS signal from a fixed installation and not
from one or two vessels.

During the same period (03:38–03:56), the OOWT and the OOWAT performed several
optical position determinations by taking bearings to verify the position in ECDIS. In
practice, this meant that the OOWT took bearings of different objects using the pelorus at
the centre of the bridge. The bearings were communicated to the OOWAT, who plotted
them on the frigate’s ECDIS to determine the frigate’s position.

The OOWA was also relieved during the same period. The relieving OOWA arrived on
the bridge at 03:49 and went through the watch handover procedure with the OOWA
being relieved until 03:56. The OOWA being relieved informed the relieving OOWA
about AIS mode, communication, navigation lights, ECDIS and radar settings, and where
they were heading. The relieving OOWA got the impression that everything was in order.
The OOWA being relieved could not remember seeing any vessels on the radar

6
Acquiring or tracking: A criterion for the navigation system to generate alarms according to set limit values for the
closest point of approach (CPA) and time until CPA (TCPA). The navigation system will not generate alarms for
vessels that are not being acquired.
7
MFD – multi functional display

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approaching from ahead when handing over the watch to the relieving OOWA. The radar
(MFD 2) operated by the OOWA had been set to the 6 nm range scale and off centre
since 02:50.

From 03:20, a night meal was being served in the mess, and it was agreed with the OOW
being relieved that members of the bridge watch team could go down to get something to
eat, one at a time. The STBD LO went down to the mess at 03:41 and was back on the
bridge at 03:48. After that, the bridge watch team rotated their positions. The STBD LO
took over as PORT LO. The PORT LO took over as HM. The HM, who was to take over
as STBD LO, went down to the mess at 03:51 and returned to the bridge at 03:59.

Figure 9 shows the crew that were present on the bridge of HNoMS Helge Ingstad during
the period from 03:40 to 03:59.

Figure 9: Crew on the bridge of HNoMS Helge Ingstad during the period from 03:40 to 03:59, a
period of watch handovers and bridge watch team rotation, when the starboard lookout had gone
down to the mess. Illustration: The Royal Norwegian Navy/AIBN

Once the handover was completed, the OOW who had been relieved went into the
chartroom and logged the watch change at 03:53 in the log book. The relieving OOW
stated out loud to everyone on the bridge that the OOW had taken over the watch and that
the OOWT was navigating. Everybody on the bridge acknowledged.

At 03:53, HNoMS Helge Ingstad was keeping a course of 158° and moving at a speed of
16.9 knots.8 The frigate caught up with and passed Dr. No on the port side, a yacht that
was also heading south through the Hjeltefjord.

The OOW focused on the three vessels that were approaching from ahead on the port
side. The OOW checked the radar and thought the three vessels had chosen a more
easterly course than previously, which would increase the CPA.9 The OOW did not check

8
One knot is equivalent to one nautical mile (1,852 m) per hour. 16.9 knots = 31.3 km/h.
9
CPA - closest point of approach

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the names of the three approaching vessels. The OOW informed the bridge team of the
three approaching vessels and asked them to notify of any further observations.

The OOW and the OOWT had a conversation during which the OOW asked the OOWT
whether they had visual contact with the approaching vessels. The OOWT answered this
in the affirmative. They did not discuss the flood-lit ‘object’ on the starboard side or
examine it further on the radar or via AIS.

The PORT LO observed the three northbound vessels carrying navigation lights on the
port side. The PORT LO also saw the yellow floodlights from the ‘object’ on the
starboard side. The PORT LO had taken a quick look through the binoculars, but not seen
any navigation lights. The PORT LO thought the floodlights came from a quay. The
PORT LO continued to use the binoculars, focusing on the vessels on the port side.

The OOWA had observed a well-lit, big, square platform, but had not given it further
thought or investigated it further. The OOWA focused on training the OOWAT.

The HM saw the floodlights after taking over the helm at 03:48 and understood that it
was a vessel. The HM believed that the lookout had notified the bridge team of all the
vessels, including the flood-lit vessel. The HM also assumed that the OOW and OOWA
were aware of it being a vessel and could see it on the AIS. The HM thought that the
vessel would pass HNoMS Helge Ingstad on the starboard side and that there was
sufficient passing distance.

1.2.2.2 Sola TS

When Sola TS had moved far enough out and the stern was clear of the quay, the tanker
continued to turn to port to set course for Fedjeosen. The pilot and master returned to the
bridge shortly before 03:45.

At this time none of the vessels approaching from the north could be observed on the S-
band radar, which had been set to a 3 nm range scale since 03:27 (see Figure 10).

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Figure 10: At 03:45, the S-band radar on Sola TS, set to a range scale of 3 nm, showed three
vessels to the south and none to the north. Source: Tsakos Columbia Shipmanagement S.A.

To the south, the northbound Silver Firda and Vestbris were visible on the display, along
with the southbound Stril Herkules. Both Silver Firda and Vestbris had notified the VTS
in English of their entry into the VTS area from the south. None of these vessels were
plotted on the radar on board Sola TS. The radar provided true trails which gave an
indication of speed and heading of other vessels (see Figure 10). The vessels that were
transmitting AIS signals, could be observed on the ECDIS on Sola TS as long as they
were within the range scale to which the instruments had been set. The visibility was
good and the bridge crew observed the surrounding vessels.

Sola TS had her lights on while moving away from the quay assisted by the two tugboats
(see section 1.10.4). The tanker also had all forward-pointing deck lights on when leaving
the Sture Terminal. Rough weather was forecast for the North Sea, and the master had
ordered the crew to secure equipment etc. on deck after departure. This primarily
consisted of putting blind flanges into place on the manifold, securing the gangway, oil
spill and fire-fighting equipment, and securing the mooring hawsers and wrapping the
hawser reels in tarpaulin.

At 03:45, as Sola TS moved further away from the lights on the Sture Terminal, the
master turned off the deck lights in the midship masts (which were pointing forward).
After that, the six forward-pointing yellow deck lights on the forward side of the
superstructure and the three forward-pointing white lights in the foremast remained on
(see section 1.10.5).

At 03:45, while the watch handover was starting on HNoMS Helge Ingstad, the pilot on
Sola TS called Fedje VTS on VHF channel 80 with the message that the tanker was

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departing the Sture Terminal and heading west through Fedjeosen. The Area North
operator at Fedje VTS confirmed receipt of the message.

The VTS operator then zoomed in on the Sture Terminal on the main work screen, in
such a way that it showed a larger area to the south than to the north of the terminal. The
operator observed three northbound vessels that were approaching and concluded that
Sola TS had enough time to turn. The northbound vessels (Silver Firda, Vestbris and
Seigrunn) were approximately 2 – 3.5 nm south of the Sture Terminal at 03:45. The two
southbound vessels, Dr. No and HNoMS Helge Ingstad were directly to the east of
Nordøytåna, 5.65 nm to the north of Sola TS, outside the range scale on the VTS
operator’s main work screen. Figure 11 shows the traffic situation in the Hjeltefjord at
03:45.

At 03:46, the pilot on Sola TS ordered rudder to port. At 03:49, the pilot dismissed the
tugboat Ajax.

The second mate and helmsman who were taking over the watch on Sola TS arrived on
the bridge at approximately 03:50 and 03:55, respectively. However, the handover
procedure had not yet started when the situation with HNoMS Helge Ingstad arose.

At 03:52, the pilot ordered a course of 350°. Sola TS was then moving at a speed over
ground (SOG) of 3.2 knots. The pilot had observed visually, probably slightly before this
time, the two southbound vessels to the north of Sola TS. HNoMS Helge Ingstad and Dr.
No in the north, and Silver Firda and Vestbris in the south, were now visible on the radar
displays on Sola TS (see Figure 12), but they were not plotted on the radar.

After that, the tanker gradually built up speed. All was calm on the bridge on Sola TS,
and the members of the bridge team were chatting while heading out to sea.

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Figure 11: The traffic situation in the Hjeltefjord at approximately 0345. The frigate had one
southbound vessel just ahead, and three northbound and one southbound vessels south of the
Sture terminal. Sola TS and the tugs Ajax and Tenax had now left the quay and started a port
turn to set a northbound course towards Fedjeosen. HNoMS Helge Ingstad was directly to the
east of Nordøytåna, 5.65 nm to the north of Sola TS. Illustration: AIBN

Figure 12: The traffic situation as displayed on the S-band radar on Sola TS at 03:51. Source:
Tsakos Columbia Shipmanagement S.A.

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1.2.3 Sequence of events during the collision phase (03:57–04:01)

At 03:57:25,10 the speed of Sola TS had increased to 6.1 knots (SOG). At this point, there
was a distance of approximately 2,720 metres between Sola TS and HNoMS Helge
Ingstad (see Figure 13). The pilot was aware of the radar echo from a southbound vessel
to the north in the fairway and had also observed the vessel’s navigation lights visually.
At that time, the southbound vessel was approaching at an angle of 10–12° on the port
bow. The pilot saw only the vessel’s green light and that the vessel would cross the
tanker’s course line. The pilot therefore requested AIS data about the vessel from the
master on Sola TS, but the master replied that the vessel was not transmitting such data.

Figure 13: At 03:57:27, there was a distance11 of approximately 2,720 metres between HNoMS
Helge Ingstad and Sola TS. Illustration: Safetec/AIBN

At 03:58:03, the pilot on Sola TS called Fedje VTS on VHF channel 80. Fedje VTS
responded immediately. The pilot requested information about the vessel: ‘Yes, do you
know the name, do you know what vessel is approaching on, towards us? She is slightly
to port.’ The Area North operator at Fedje VTS replied at 03:58:30, stating that they had
no information about the vessel: ‘There is … have not received any information about it.
It has not been reported to me, I only have an echo on the screen here.’

The radar image from Fedje VTS (see Figure 14) shows that the vessels HNoMS Helge
Ingstad, Sola TS with the tug Tenax, Silver Firda, Vestbris and Seigrunn were all present
in the area around the Sture Terminal at 03:59.

10
The specified times are taken from the sources of the information (Sola TS’ Voyage Data Recorder (VDR), Fedje
VTS’ monitoring system, HNoMS Helge Ingstad’s Integrated Platform Management System (IPMS) and navigation
system).
11
The calculation of the distances between the vessels (bow to bow) is based on VDR data from Sola TS and the
frigate’s navigation system. The sizes and antenna positions of the vessels have been taken into account.

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At 03:58:54, after receiving the call from Sola TS, the Area North operator at Fedje VTS
plotted the echo on the radar without AIS. He saw that a vector appeared on the screen
indicating that Sola TS and the other vessel were on course to collide.

Figure 14: Screenshot of the radar replay from Fedje VTS, showing the traffic situation near the
Sture Terminal at 03:59. Source: NCA

The OOW on HNoMS Helge Ingstad eventually noticed that the ‘object’ on the starboard
side seemed to be closer to the frigate’s course line than first assumed, leaving less
distance to the closest point of approach. The OOW has stated that the ‘object’ was
primarily observed visually and that the OOW did not check the radar for details.

At 03:59:02, when there was a distance of approximately 1,510 metres between the
vessels (see Figure 15), the pilot asked the master on Sola TS to use the Aldis lamp12 to
send out signals to the vessel. According to their statements, both the master and the pilot
had, shortly after signalling with the Aldis lamp, observed both sidelights on HNoMS
Helge Ingstad and thought that the vessel was turning to starboard. The master also
observed that the two masthead lights on HNoMS Helge Ingstad were not in line and
perceived the red sidelight to be clearer than the green sidelight. Shortly afterwards, they
only saw the green light, and so they continued sending out light signals with the Aldis
lamp.

The Area North operator at Fedje VTS has also stated that, on his screen, it briefly (at
03:59:16) appeared as if the vessels would go clear of each other, before they were
observed to be on collision course shortly afterwards (at 03:59:25).

12
An Aldis lamp is a signalling device used to send out light signals.

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Figure 15: At 03:59:07, there was a distance13 of approximately 1,510 metres between HNoMS
Helge Ingstad and Sola TS. Illustration: Safetec/AIBN

At 03:59, Sola TS was moving at a speed of 6.7 knots (SOG) with the course set to 350°.
At 03:59:21, the pilot on Sola TS asked the helmsman to change course from 350° to
000°, i.e. 10° to starboard to indicate to the approaching vessel that they were making an
evasive manoeuvre.

At 03:59:26, HNoMS Helge Ingstad was keeping a course of 157° and moving at a speed
of 17 knots. The OOW asked the OOWT to adjust the course by some degrees to port.
The OOWT asked whether he should change course to port, which the OOW confirmed.
The OOWT conveyed the message to the HM. At 03:59:30, HNoMS Helge Ingstad
started to turn to port, ending up at 147° at 04:00:46 (see Figure 42 in section 1.15.1.2).

The HM focused on the rudder orders that were issued, but glanced around from time to
time and saw that the vessel on the starboard side was getting closer. The vessel appeared
to be on a parallel course with HNoMS Helge Ingstad, and the HM thought that it
planned to pass HNoMS Helge Ingstad on the starboard side. When the vessel came even
closer, the HM felt dazzled by the floodlights.

The STBD LO on HNoMS Helge Ingstad, who had returned to the bridge after a night
meal at 03:59, observed a lot of light forward on the starboard side, thinking it was a quay
or similar because of all the lights and the nearness of the ‘object’.

Some time after receiving the first call from the pilot on Sola TS, the Area North operator
remembered that HNoMS Helge Ingstad had previously (at 02:38) notified of entering the
VTS area. The VTS operator immediately called the pilot on Sola TS on VHF channel
80:

- Fedje VTS called Sola TS at 03:59:40.

13
See footnote 11.

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- At 03:59:46, the pilot on Sola TS replied to the call.

- Fedje VTS to Sola TS at 03:59:47: ‘It is possibly Helge Ingstad; he entered from the
north a while ago. It could be that he is the one approaching.’

The OOW on HNoMS Helge Ingstad became aware of the VHF call just after having
asked the OOWT to change course. The OOW went over to the VHF radio (see section
1.9.4) to reply.

At this point (03:59:57), there was a distance of approximately 875 metres between the
two vessels (see Figure 16).

Figure 16: At 03:59:57, there was a distance14 of approximately 875 metres between ‘HNoMS
Helge Ingstad’ and Sola TS. Illustration: Safetec/AIBN

- At 03:59:56, the pilot on Sola TS called immediately HNoMS Helge Ingstad: ‘Helge
Ingstad, do you hear Sola TS?’

- At 04:00:02, the OOW on HNoMS Helge Ingstad replied: ‘Helge Ingstad’.

- At 04:00:04, the pilot on Sola TS replied: ‘Is that you approaching?’.

- At 04:00:06, the OOW on HNoMS Helge Ingstad replied: ‘Yes, it is’.

- At 04:00:08, the pilot on Sola TS replied: ‘You must turn to starboard immediately’.

- At 04:00:11, the OOW on HNoMS Helge Ingstad replied: ‘No, then we will sail too
close to eh... blokkene/båkene’.15

14
See footnote 11.
15
The exact word that is spoken is unclear and the OOW cannot explain it in retrospect, but the phrase is related to the
illuminated ‘object’.

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- At 04:00:15, the pilot on Sola TS replied: ‘Turn starboard if you are the one
approaching.’

- At 04:00:27, the OOW on HNoMS Helge Ingstad replied: ‘I … a few degrees to

starboard as soon as we have passed eh …, passed eh … the platform on our
starboard side’.

The OOW on HNoMS Helge Ingstad understood the call to be from one of the three
northbound vessels that wanted the frigate to go further to starboard to increase the
passing distance. The OOW still thought the ‘object’ on the starboard side was stationary
and that they could not go further to starboard without getting too close to the ‘object’.

At this point (04:00:27), there was a distance of approximately 500 metres between the
two vessels (see Figure 17). At 04:00:20, Sola TS was steering to a course of 355°, still
altering course to starboard, while the course over ground (COG) was 345.8°, and it was
moving at a speed of 7.2 knots (SOG). At 04:00, HNoMS Helge Ingstad was moving at a
speed of 16.9 knots. HNoMS Helge Ingstad had a course of 152.5° at 04:00:26 and of
149.7° at 04:00:36.

Figure 17: At 04:00:27, there was a distance16 of approximately 500 metres between HNoMS
Helge Ingstad and Sola TS. Illustration: Safetec/AIBN

The rest of the bridge team on HNoMS Helge Ingstad heard the OOW talking on the
VHF radio, but did not catch all the details of what was being said. The lights on the
starboard side were getting closer, but they believed that the OOW was in control of the
situation. The helmsman (HM) who, so far, had been at the helm and steered using one of
the tillers, has stated that the approaching vessel appeared to have altered course to
starboard and that it was very close. The HM therefore got up from the chair and, from
04:00:36, steered using both rudder handles.

16
See footnote 11.

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At 04:00:30, the master on Sola TS called out ‘stop engines’. Sola TS was then moving at
a speed of 7.2 knots (SOG).

The VTS operator at Fedje VTS had registered that there was radio contact between Sola
TS and HNoMS Helge Ingstad and did not want to intervene. The operator has explained
that the whole situation was incomprehensible. He did not understand why HNoMS
Helge Ingstad replied that they could not go further to starboard. However, in the end, the
VTS operator did call HNoMS Helge Ingstad at 04:00:44: ‘Helge Ingstad, you must do
something. You are getting very close.’ At this point (04:00:47), there was a distance of
250 metres between the two vessels (see Figure 18).

Figure 18: At 04:00:47, there was a distance17 of 250 metres between ‘HNoMS Helge Ingstad’
and Sola TS. Illustration: Safetec/AIBN

The OOW on HNoMS Helge Ingstad was standing next to the VHF radio handset on the
starboard side of the bridge. The OOW suddenly realised that the ‘object’ that was giving
off light was moving and that they were on direct collision course. The others on the
bridge also saw a lot of light on the starboard bow and realised that HNoMS Helge
Ingstad was going to collide.

At 04:00:50, the pilot on Sola TS ordered full speed astern on the engines. At 04:01:03,
the Area North operator made another call to HNoMS Helge Ingstad: ‘Helge Ingstad,
there will be a collision.’

The OOW on HNoMS Helge Ingstad ordered rudder 20° to port, understanding that it
was too late to turn to starboard. The HM moved both tillers to port, but the rudder had
not moved more than 10° to port when the OOW issued a counter-order to set the handles
to midship. This had the effect of changing the course of HNoMS Helge Ingstad from
147.2° to 145.7°.

17
See footnote 11.

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The two vessels collided outside the Sture Terminal in the Hjeltefjord at 04:01:15 (see
Figure 19)

Figure 19: The point of impact when HNoMS Helge Ingstad and Sola TS collided outside the
Sture Terminal in the Hjeltefjord at 04:01:15. Illustration: AIBN

1.3 The rescue operation

Additional information about the rescue operation will be published in the final
investigation report. The following is mentioned here:

- After the collision, Fedje VTS notified the Joint Rescue Coordination Centre (JRCC),
the NCA’s emergency response department and the VTS manager in accordance with
a dedicated list.

- At 04:10, HNoMS Helge Ingstad sent a ‘DSC distress’ call18, and notified verbally
that they had run aground.

- At 04:15, the JRCC assumed responsibility for coordinating the rescue operation.

- At 04:23, HNoMS Helge Ingstad notified that all 137 persons on board had been
accounted for.

- At 04:33, Sola TS notified that they had gained an overview of the situation.

- At 04:50, HNoMS Helge Ingstad notified that they had lost control of the frigate’s
stability and would have to evacuate.

- At 05:05, HNoMS Helge Ingstad started to evacuate all but 10 personnel who still
remained on the bridge.

- At 06:34, the final 10 were evacuated to the coast guard vessel NoCGV Bergen. The
decision to do so was based on an overall assessment of the situation on board.

18
Distress message via the VHF Digital Selective Calling system

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1.4 Description of injuries/damage

1.4.1 Personal injuries

Seven crew members on HNoMS Helge Ingstad sustained minor physical injuries. None
of the crew on Sola TS were injured in the collision.

1.4.2 Damage to the vessel

1.4.2.1 HNoMS Helge Ingstad

In the collision with Sola TS, HNoMS Helge Ingstad suffered extensive damage along
the starboard side (see Figure 20). The damage caused flooding, a break in the starboard
seawater line, severing of several electrical cables, extensive damage to the aft conscripts
quarter, as well as damage to the torpedo magazine. Detailed information about the
damage will be published in the final investigation report.

Figure 20: Damage to the hull along the starboard side of HNoMS Helge Ingstad after the
collision. Photo: The Norwegian Coastal Administration

1.4.2.2 Sola TS

The tanker’s starboard anchor was the first point of contact in the collision between
HNoMS Helge Ingstad and Sola TS. The anchor and 20 m of the anchor chain were
ripped out. The collision also caused damage to the hawsepipe and left a small hole in the
hull just aft of the hawsepipe (see Figure 21). Parts of the bulwark above the anchor were
indented.

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Figure 21: The hawsepipe and the damage sustained by Sola TS in the collision. The hole in the
hull is marked with a white circle. Photo: The Norwegian Maritime Authority

1.4.3 Spills and damage to the natural environment

The environmental surveys of farmed fish, shellfish and sediments in the area around the
shipwreck of HNoMS Helge Ingstad were performed by the Institute of Marine Research
on assignment for the NCA, which led the oil-spill response operation to limit the
environmental damage after the accident. The NCA’s final accounts after the accident
show that HNoMS Helge Ingstad had 500 m3 of oil on board, including 460 m3 of marine
diesel. In total, 284 m3 of marine diesel leaked out into the Hjeltefjord. The following was
stated in the report by the Institute of Marine Research (Boitsov and Klungsøyr, 2019):

(…) No traces of oil pollution were found in the salmon samples. In the mussel
and sediment samples, oil pollution from the frigate was only found locally within
a limited area from the shipwreck. The oil spill is therefore considered to have
had little impact on the marine environment, and further environmental surveys
relating to the incident are considered unnecessary.

1.5 Weather and sea conditions

1.5.1 General information

Coinciding weather observations at the time of the accident were reported by the
Meteorological Institute (Fedje weather station), Fedje VTS, Sola TS and HNoMS Helge
Ingstad. A south-southeasterly wind was blowing at a speed of 7 m/s and the sea was
calm. It was a starlit night and visibility was good. There was no rain in the area and no
moonlight. See also Appendix A, which shows data from the weather stations in the area,
provided by the Meteorological Institute.

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1.5.2 Information about current conditions from the Meteorological Institute

The Meteorological Institute has not measured current conditions in the area. The AIBN
has obtained calculations based on a numerical ocean model with a grid of approximately
800x800 m; see Appendix A. The model shows a northerly current moving at a speed of
approx. 0.5 m/s in the accident location at the time of the accident. There is some
uncertainty attached to model calculations of this kind. The Meteorological Institute
assumes that the current direction in this case is correct, but that the speed is more
uncertain.

1.6 The Hjeltefjord and the traffic situation

1.6.1 The Hjeltefjord

The accident occurred in the Hjeltefjord north of Bergen.

The Hjeltefjord belongs to the Fedje VTS area (see section 1.13.3.1). The Fedje VTS area
is divided into Area North and Area South, with the boundary at Jona light near the
southern end of the Hjeltefjord.

There are three major quay facilities in the Hjeltefjord serving the offshore oil and gas
industry. In addition to the loading facilities at the Sture Terminal, there are maintenance
and supply bases at Ågotnes and Hanøytangen, where several ships and oil rigs are
normally docked for maintenance purposes.

The Directorate of Fisheries’ map solution Yggdrasil shows that there are several
different aquaculture locations along both sides of the Hjeltefjord. The perimeter of such
facilities is normally marked with flashing lights, and the barges will also carry lights.

1.6.2 Traffic situation in the area

HNoMS Helge Ingstad sailed out the southern end of Krakhellesundet and continued in a
south-westerly direction across Sognesjøen. At approximately 02:38, HNoMS Helge
Ingstad was directly south of Ytre Steinsund, approximately 4 nm north-east of the
boundary, and reported to Fedje VTS that they would enter the area from the north.

As HNoMS Helge Ingstad approached Holmengrå, the supply vessel Siem Pride was
heading out to sea to the west of the frigate. The well boat Ronja Nordic was northbound
and about to enter Brosmeosen. There were three vessels further south in the fairway
between Fedje and Austrheim and Radøy: the southbound yacht Dr. No, and the
northbound Odin and Kirsti H (see Figure 22). All of these vessels transmitted AIS-data,
with the exception of HNoMS Helge Ingstad.

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Figure 22: The traffic situation at Fedje at approx. 03:09 on 8 November 2018.
Source: AIBN

At 03:34:30, HNoMS Helge Ingstad disappeared from Fedje VTS’s radar display. At that
time, the frigate was just east of Langøybukta. HNoMS Helge Ingstad reappeared on the
radar display at Fedje VTS after 2 to 3 minutes19.

When Sola TS departed from the Sture Terminal at approximately 03:45, HNoMS Helge
Ingstad was directly to the east of Nordøytåna. They were about to catch up with and pass
the yacht Dr. No. Maritime traffic further south in the Hjeltefjord consisted of three
northbound vessels – Silver Firda, Vestbris and Seigrunn, and one southbound vessel –
Stril Herkules. Figure 23 shows the traffic situation in the area at approximately 03:53.
All these vessels transmitted AIS-data.

19
The actual area was covered by the radar at Marøy, which had some technical issues the night of the accident.
HNoMS Helge Ingstad disappeared from Fedje VTS’s radar display only 2 – 3 minutes. The AIBN has not investigated
this further.

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Figure 23: The traffic situation at 03:52:55 on 8 November 2018. Source: AIBN

1.6.3 Traffic situation in the Fedje VTS area from 00:00 until 04:00

The AIBN has prepared an overview of the traffic situation in the Fedje VTS area during
the night of the accident on the basis of radio communication on VHF channel 80
between Fedje VTS and the vessels in the area.

The traffic situation was normal for that time of night, and Fedje VTS communicated
with a total of 20 vessels during this four-hour period. Seven vessels notified of entering
the VTS area from the north at Sognoksen, one at Fedjeosen and four from the south. The
other vessels notified of departure, of moving inside the VTS area or of leaving the area.
In the period from HNoMS Helge Ingstad entered the area and until 0350, there were 11
calls between Fedje VTS and 9 vessels.

The three northbound vessels in the vicinity of the accident location reported entering the
traffic area at 03:15:37 (Silver Firda in English), 03:16:32 (Vestbris in English) and
03:26:00 (Seigrunn in Norwegian), respectively.

1.7 Automatic Identification System (AIS)

1.7.1 General information

The International Maritime Organization (IMO) has introduced an amendment to the

International Convention for the Safety of Life at Sea (SOLAS), whereby AIS is required
on passenger and cargo ships of a certain size. The requirement has subsequently been
extended to include other types of vessels. AIS is a supplement to radar-based

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information on board ships and at the VTS centres. Together, AIS and the radar tracking
systems provide an almost complete picture of the maritime traffic situation in the
coverage area.

The AIS system consists of transceivers on ships that transmit unique signals to other
ships, land-based AIS base stations and satellites. The data from the base stations are then
made available for VTS centres and other public agencies. Furthermore, the AIS image is
made available to «the public» through Kystinfo and BarentsWatch20. The signals include
information about the vessel, its position, speed and course. AIS transponders can also be
used to transmit information from other installations, buoys, beacons and marks, and in
search and rescue (SAR) helicopters and aircraft.

1.7.2 Rules and regulations

According to the Regulations of 5 September 2014 No 1157 on navigation and

navigational aids for ships and mobile offshore units (Regulations on Navigational Aids
for Ships etc.), AIS shall be carried by all passenger ships engaged on foreign voyages,
passenger ships of 300 gross tonnage (GT) and upwards engaged on domestic voyages,
passenger craft of 150 GT and upwards engaged on domestic voyages capable of a
maximum speed of 20 knots or more, cargo ships of 300 GT and upwards, and mobile
offshore units. Fishing vessels of 15 metres and more are also required to carry AIS.
Recreational and other craft that are not obliged to carry AIS, may also install and use the
system. AIS data can be integrated in the electronic charts (ECDIS).

All vessels required to use AIS shall use AIS Class A transceivers. AIS shall be in
operation at all times, but may be deactivated when necessary for the safety and security
of the vessel.

Naval vessels are not required to use AIS. It is clear from the Navy’s regulations on
inshore navigation (SNP-500, see section 1.11.6) that the Navy recognises that the
original and most important function of AIS is anti-collision, and it is on this basis that
AIS rules are issued. SNP-500 stresses that if the transmission and, if applicable, receipt
of AIS data are deactivated, the navigation team must be particularly observant and
vigilant in relation to approaching traffic, especially in the dark and in conditions of poor
visibility. SNP-500 contains the following rules, among others, for the use of AIS:

- All military vessels shall comply with civil regulations concerning the use of AIS.

- Deviations from civil regulations shall be based on conscious decisions and be known
to all members of the navigation team. In such cases, special vigilance must be
exercised in relation to other vessels.

1.7.3 Coverage and update frequency

The AIS base stations along the coast and AIS equipment on board the vessels are based
on VHF radio signals. These have a limited range, which means that some parts of the
fjords in Western Norway have poor or no AIS coverage. AIS coverage in the Hjeltefjord
is good.

20
Kystinfo is the NCA’s online map service.
BarentsWatch is a Norwegian management and information system for the northern coastal and sea areas.

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The AIS transponders depend on reliable positioning systems. Any inaccuracies in the
global positioning system (GPS) will be reflected in the AIS position. Inaccuracies can
arise as a result of atmospheric conditions, but can also be a result of conscious
manipulation/blocking (GPS jamming). The investigation found no interference in GPS
signals or inaccuracies in the GPS system at the time of the accident.

AIS Class A transceivers transmit dynamic information at intervals of between 2 seconds

and 3 minutes, depending on the vessel’s speed, course changes or requests from the base
station.

1.7.4 Warship AIS (W-AIS)

Warship AIS, also called Blue Force AIS, encrypted AIS or secure AIS, is a mode
selectable on compatible AIS transponders, which broadcasts the vessel’s AIS
information in an encrypted format. The encryption keys used for W-AIS are generated
with commercially available encryption algorithms. W-AIS information can be displayed
by compatible AIS units with the correct encryption key installed. For NATO vessels that
use W-AIS, the system requirements are given in the NATO standard STANAG21 4668
(Edition 2). W-AIS may also be used in accordance with this STANAG, by other
government authorities.

1.8 Personnel information

1.8.1 HNoMS Helge Ingstad

1.8.1.1 General information

HNoMS Helge Ingstad had 137 persons on board. The mix of conscripts and permanent
crew was normal. There was no rotation of the crew. The crew earned time off in lieu per
voyage day, which was to be taken out when the vessel lay alongside or in other
appropriate situations. The frigate only had one crew.

1.8.1.2 Crew and bridge watch system on the night of the accident

A total of seven watchstanding personnel were present on the bridge of HNoMS Helge
Ingstad during the night leading up to 8 November: the officer of the watch (OOW), the
officer of the watch trainee (OOWT), the officer of the watch assistant (OOWA), the
officer of the watch assistant trainee (OOWAT), and the bridge watch team consisting of
two lookouts and a helmsman.

The OOWs and OOWTs were qualified officers, while the remaining personnel on the
bridge were conscripts or undergoing apprenticeship22 to become, for example, able
seamen.

Table 1 shows the hours worked by the bridge personnel during this particular voyage.

21
NATO Standardization Agreement 4668 – Warship – Automatic Identification System (W-AIS)
22
The apprenticeship scheme is organised by the Navy’s personnel department. The purpose is to give apprentices an
opportunity to complete their national service and the apprenticeship period at the same time, in the course of two
years’ service on board.

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Table 1: Watch systems worked by the bridge personnel during the voyage
Position Watch
Officer of the watch (OOW) 4 hours on – 8 hours off
Officer of the watch trainee (OOWT) 6 hours on – 6 hours off
Officer of the watch assistant (OOWA) 4 hours on – 8 hours off
Officer of the watch assistant trainee 6 hours on – 6 hours off
(OOWAT)
Bridge watch team 3 hours on – 9 hours off

On HNoMS Helge Ingstad, three cleared officers of the watch were present on the bridge
during the day, along with three officer of the watch trainees. The OOW and the OOWA
had worked ordinary sea watches during the NATO exercise Trident Juncture, i.e. 4
hours on, 8 hours off. On this particular day, the OOWT and the OOWAT were working
to a 6 hours on/6 hours off watch system to earn as much navigational practice time as
possible. On this particular watch, the training goal for the OOWT was to gain more
independence in the role of navigator.

The bridge watch team, which consisted of conscripts, had worked 6 hours on/6 hours off
during Trident Juncture, but had been back on normal sea watches since the night leading
up to Wednesday 7 November 2018. HNoMS Helge Ingstad had enough personnel on
board to form four bridge watch teams, and they could therefore work three-hour watches
in daytime and during the night. The bridge watch team rotated between the positions of
port lookout, helmsman and starboard lookout at one-hour intervals.

Figure 24 shows the personnel present on the bridge around the time of the accident,
including how long each of them had been on watch and the bridge watch team’s change
of positions. The average age of the members of the bridge team was 22.4 years.

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Figure 24: Personnel on the bridge at the time of the accident, at 04:01:15. Illustration: AIBN

1.8.1.3 Duties and responsibilities on the bridge23

The officer of the watch (OOW) was responsible for the safe and secure navigation of the
vessel and for all training activities on the bridge, approved the OOWT’s decisions and
had a duty to take over navigation at any time, should this prove necessary.

The officer of the watch trainee (OOWT) navigated the vessel and performed all duties
normally assigned to the OOW (except for VHF communication), including monitoring
traffic, monitoring the vessel’s position in the fairway and issuing orders to the
helmsman.

The duty of the officer of the watch assistant (OOWA) was to monitor the voyage on the
ECDIS and radar. The assistant is required to assist the OOW/OOWT and may get
questions related to navigation, can inform about any upcoming course changes if these
have been plotted and about beacons etc. It was the OOWA’s duty to train the OOWAT
on this voyage.

The duty of the officer of the watch assistant trainee (OOWAT) was to plot optical
bearings on the ECDIS display.

The frigate always used a helmsman and manual steering during inshore voyages.

23
Reference is also made to section 1.11.7.2 for a more detailed description of the bridge manual.

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The duty of the helmsman (HM) was to execute orders from the OOW/OOWT.
Executing orders at the helm means to steer a steady course or set the rudder to a specific
position (number of degrees to starboard or port) on the orders of the navigator.

The lookouts were tasked with looking out for relevant information, vessels and other
potential dangers to navigation, and with notifying the OOW/OOWT of their
observations in accordance with established procedures.

It was normal practice for the Commanding Officer (CO) and the executive officer (XO)
to spend a great deal of time on the bridge and in the operations room during inshore
navigation. The CO and the XO have no specific duties on the bridge during voyages,
other than to provide support as needed and to ensure that the navigators and bridge crew
navigate safely and tend to their duties. Both the CO and the XO were present during part
of the training of new navigators to form an impression of how they were doing. The CO
and/or the XO were always present on the bridge when passing through areas of maritime
traffic and/or narrow fairways, and in conditions of poor visibility. On the night in
question, the CO had been on the bridge several times during the southbound voyage in
inshore waters.

1.8.1.4 Commanding officer (CO)

The CO had held the position of commanding officer on board HNoMS Helge Ingstad for
2 years and 3 months when the accident occurred. After completing education at the
Royal Norwegian Naval Academy, the CO served for 15 years in different officer
positions and as commanding officer on board the navy`s fast patrol boats. From 2013,
the CO held the position as operational officer on board several of the navy's frigates, and
from 2014 as executive officer.

1.8.1.5 Officer of the watch (OOW)

The OOW being relieved (00–04 watch) had been a navigator on several of the Navy’s
frigates and had a civilian degree in navigation. The OOW had also served on board
Skjold-class corvettes for three years and on a merchant vessel operating along the
Norwegian coast for about one year.

The relieving OOW (04–08 watch) had held clearance as officer of the watch for about
eight months when the accident occurred. The OOW was a graduate of the Norwegian
Naval Academy and had been cleared as officer of the watch after nine months’ training
on HNoMS Helge Ingstad. The OOW had held the position as Navigation Officer 1 for
three months (see section 1.11.5.2).

The night before the accident, the relieving OOW had gone to bed at around 22:00. After
approximately 5.5 hours’ sleep, the OOW got up around 03:30 to go on watch, arrived on
the bridge at approximately 03:40 and took over the watch at 03:53. The OOW
sometimes slept an hour in the middle of the day, but had not slept during the day on 7
November 2018.

1.8.1.6 Officer of the watch trainee (OOWT)

The OOWT was an English-speaking exchange officer from another NATO country. The
OOWT had worked on Norwegian frigates since 2017. The OOWT was seeking to gain

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navigational experience and to prepare for the theoretical exam, the first step in the
qualification process for OOWs.

The OOWT normally worked the 00–04 watch. In connection with the navigational
training on this particular day, the OOWT worked 6-hour watches. The day before the
accident, the OOWT had gone to bed at around 21:30 and slept for about 4.5 hours. The
OOWT arrived on the bridge at 02:18.

1.8.1.7 Officer of the watch assistant (OOWA)

The OOWA being relieved (00–04 watch) was in the process of completing the period of
national service and had previously acquired an able seaman’s certificate. The OOWA
was part of the Seamanship section24 on HNoMS Helge Ingstad, working on ship
maintenance and serving as an OOWA during voyages.

The relieving OOWA (04–08 watch) had begun an apprenticeship as an able seaman after
completing the period of national service and had served on board HNoMS Helge Ingstad
for 14 months.

The day before the accident, the relieving OOWA had gone to bed at around 21:30–22:00
and slept for about 5.5–6 hours. The OOWA arrived on the bridge at approximately
03:45.

1.8.1.8 Officer of the watch assistant trainee (OOWAT)

The OOWAT was in the process of completing the period of national service and was
undergoing apprenticeship as an able seaman on board HNoMS Helge Ingstad. The
OOWAT had completed an IMO 60 safety course and basic maritime courses and had
signed on HNoMS Helge Ingstad about two weeks before the accident.

The OOWAT was normally on the 04–08 watch. In connection with the navigational
training on this particular day, the OOWAT worked 6-hour watches. The day before the
accident, the OOWAT had worked the 14:00–20:00 bridge watch, before going back on
watch at 02:00.

1.8.1.9 Helmsman (HM)

The HM was completing the period of national service and had signed on HNoMS Helge
Ingstad four months before the accident. The HM served as gunner on board, in addition
to being part of the bridge watch team during voyages.

The HM came on watch together with the rest of the bridge watch team at 02:00. The HM
served as starboard lookout for the first hour, then as port lookout and took over at the
helm at 03:48.

24
The Seamanship section on a frigate consists of the boatswain (OR 5-6), two boatswain assistants (OR 2-4), two to
four able seaman apprentices and a number of conscripts. Members of this section have many functions on board a
frigate, including on the bridge team, where they serve as lookout, helmsman and officer of the watch assistant.

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1.8.1.10 Starboard lookout (STBD LO)

The STBD LO was completing the period of national service and worked as a
logistics/supplies assistant on HNoMS Helge Ingstad, in addition to being part of the
bridge watch team during voyages.

The STBD LO came on watch together with the rest of the bridge watch team at 02:00.
The STBD LO first served as port lookout for an hour and then as helmsman. The STBD
LO went down to the mess for a night meal at 03:51 and was back on the bridge at 03:59,
taking over as starboard lookout.

1.8.1.11 Port lookout (PORT LO)

The PORT LO was completing the national service and had signed on HNoMS Helge
Ingstad eight months before the accident. The PORT LO held the position of gunner,
served on the bridge watch team and was a qualified breathing apparatus (BA) firefighter.
The PORT LO had completed an IMO 60 safety course as well as basic maritime courses
and firefighting courses.

The PORT LO came on watch together with the rest of the bridge watch team at 02:00,
serving as helmsman for the first hour, then as starboard lookout. The PORT LO went
down to the mess for a night meal at 0341, before taking over as port lookout at 03:48.

1.8.2 Sola TS

1.8.2.1 General information

Including the pilot, there were a total of 24 persons on board Sola TS.

1.8.2.2 Crew and bridge watch system

There were four deck officers on board Sola TS. Three of them worked four-hour shifts
followed by eight hours off, regardless of whether they were on sea watches or
loading/offloading watches. The chief mate followed loading and offloading operations
while the vessel was alongside, but did not work navigational watches on the bridge.

During the departure from the Sture Terminal, the bridge was manned by the master,
pilot, navigation officer on watch and helmsman. The relieving navigating officer arrived
on the bridge at approximately 03:50, while the able seaman who was taking over as
helmsman arrived at approximately 03:55. At the time of the collision, a total of six
persons were present on the bridge. The average age of the members of the bridge team
was 42 years.

1.8.2.3 Duties and responsibilities on the bridge

According to the shipping company’s navigation procedures manual (see section

1.12.2.3), while sailing along the coast or with a pilot, the master (or chief mate) shall be
in command and control of the vessel’s movements in accordance with the International
Regulations for Preventing Collisions at Sea (COLREGs). The commanding officer shall
make course and speed adjustment, monitor the navigation and coordinate the activities
of the bridge watch team.

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The navigation officer on watch shall follow the master’s instructions. The navigation
officer’s primary responsibility is collision avoidance and monitoring of the ship’s
position. The navigating officer’s duties include:

- operating the radar/ARPA25 and other navigational equipment capable of plotting

targets within a range;

- monitoring the vessel’s course, speed and position;

- reporting navigation information to the master as necessary and ensuring correct

acknowledgement by the master;

- acknowledging rudder and engine orders received and executing them;

- maintaining the bridge log and other records.

1.8.2.4 Master

The master was employed by the shipping company in 2017 and had previously served as
master on three of the company’s vessels, including Sola TS. The master had served as
master on tankers since 2005. The master signed on Sola TS four months before the
accident. The master has also made two subsequent calls at this terminal. The captain did
not speak or understand Norwegian.

1.8.2.5 Navigation officer

The navigation officer on the 00–04 bridge watch was the tanker’s second mate. The
second mate signed on Sola TS about four months before the accident. The second mate
has worked for the shipping company for almost 9 years, including as second mate for the
past 7.5 years. The second mate was the vessel’s navigating officer with special
responsibility for voyage planning, among other things. Before signing on Sola TS, the
second mate had served on board one of her sister ships for 8.5 months. The second mate
did not speak or understand Norwegian.

The navigating officer on the 04–08 watch, who arrived on the bridge at approx. 03:50 to
relieve the second mate, had served on board Sola TS for one month and worked for the
shipping company for more than six years. The navigating officer did not speak or
understand Norwegian.

1.8.2.6 Helmsman

The helmsman on the 00–04 watch was an able seaman and had worked for the shipping
company for 11 years. The helmsman had served on nine of the shipping company’s
vessels, including a sister ship of Sola TS. The helmsman signed on Sola TS about two
and a half months before the accident. The helmsman did not speak or understand
Norwegian.

The helmsman on the 04–08 watch, who arrived on the bridge at approximately 03:55 to
take over from the helmsman being relieved, was an able seaman who had worked for the
shipping company for six years. The helmsman had served on eight of the shipping

25
ARPA – Automatic Radar Plotting Aid

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company’s vessels, including two sister ships of Sola TS. The helmsman signed on Sola
TS about two and a half months before the accident. The helmsman did not speak or
understand Norwegian.

1.8.3 The pilot

The pilot on Sola TS got his pilot license in 2008 and had worked 15 years at sea before
that. The pilot is employed by the NCA’s pilotage service (see section 1.13.4). The pilot
was qualified for large tonnage at Sture since 2011. The pilot had been on board Sola TS
on several previous occasions. On 7 November, the pilot had a pilotage assignment from
14:25 to 17:10. He departed for the assignment on Sola TS at 01:50 on 8 November.

1.8.4 Fedje VTS

1.8.4.1 Area North operator

The Area North operator started as a VTS operator ten years ago. The operator had
several years of experience of working on board international ferries, both as navigator
and able seaman. The operator had also worked as an express boat navigator in Western
Norway for a period of about 11 months.

The VTS operator had just returned to work after a free period of approximately one
week. The operator had gone on duty at approximately 23:45 on Wednesday 7 November
2018 and was scheduled to be relieved at 08:00 the following day. Everything appeared
normal and it had been a quiet night with little traffic up until the accident occurred. The
operator had not slept since the morning on the day preceding the night shift. He felt well
rested in the operator’s own opinion and generally did not find working night shifts
problematic.

1.8.4.2 Area South operator

The Area South operator started as a VTS operator about ten years ago. The operator had
several years of experience, working as an officer in various positions, including on large
chemical tankers for 20 years, and at the Mongstad terminal for 2.5 years.

1.9 The frigate HNoMS Helge Ingstad

1.9.1 General information

HNoMS Helge Ingstad (see Figure 25) was a Norwegian Fridtjof Nansen-class frigate,
based at the Haakonsvern naval base in Bergen. The frigate was owned by the Norwegian
State Ministry of Defence, and managed on behalf of the owner, by the Norwegian
Defence Materiel Agency (NDMA). The Norwegian Navy was the operator of the frigate.
The frigate was built by Navantia in Ferrol in Spain. HNoMS Helge Ingstad was the
fourth in a line of five frigates built and handed over to the Norwegian Navy between
2006 and 2011, and was delivered in 2009.

The vessel had a length overall of 133.25 m and breadth of 16.8 m. The propulsion
system consisted of two BAZAN BRAVO 12V diesel engines and one GE LM2500 gas
turbine, with an engine power of 2 x 4.5 MW and 1 x 21.5 MW, respectively.

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The Navy’s frigates were not equipped with voyage data recorders (VDR), and there are
therefore no audio records of the situation on the bridge on the night of the accident (see
also section 1.11.10).

Figure 25: The frigate HNoMS Helge Ingstad. Photo: Anton Ligaarden/Norwegian Armed Forces

1.9.2 Bridge design and layout

The bridge on HNoMS Helge Ingstad was largely equipped and designed in the same
way as the bridge on the sister frigates. Most of the navigation equipment was placed in
consoles along a more or less straight transverse line; see Figure 26. The bridge team
were positioned next to each other, except for the helmsman, who stood midship a little
further aft, to allow movement transversely between the helm and the control console.

Figure 26: Bridge design on HNoMS Helge Ingstad. Position of VHF radios. See Figure 3 for
information about the bridge team’s positions on the night of the accident. Illustration: The Royal
Norwegian Navy/AIBN

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The bridge had 22 windows in total, of which 11 faced forward; all separated by robust
dividing bars (see Figure 27). The lookouts had to keep watch from inside the bridge at
all times, since the frigate lacked traditional bridge wings, and they were therefore
positioned at the far corners.

The following comment was made concerning the noise level on the bridge in connection
with DNV GL’s classing (24 November 2014) of the frigate:

Bridge ventilation system is so noisy that it is difficult for the bridge team to
communicate in a normal manner. Excessive levels of noise interfering with voice
communication, causing fatigue and degrading overall system reliability, shall be
avoided. (noted during visit on-board)

The Norwegian Defence Logistics Organisation26 (NDLO) did not implement any
measures or changes based on DNV GL’s comment:

The noise levels on Bridge is within the limit of RAR27 regulations, and no further
actions are considered by NDLO.

Figure 27: The bridge on HNoMS Helge Ingstad was near identical to the bridge on HNoMS Thor
Heyerdahl shown in the photo. The officer of the watch’s chair can be seen in the foreground.
Photo: AIBN

26
Norwegian Defence Materiel Agency (NDMA) at the time of the accident and today.
27
Rules and Regulations of the Royal Norwegian Navy

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1.9.3 Navigational aids28 – function and use

1.9.3.1 K-Bridge Integrated Bridge System

The navigation system on Fridtjof Nansen-class frigates is based on the K-Bridge

Integrated Bridge System from Kongsberg Maritime, with additional software
functionality to support military navigation. K-Bridge is a commercially available
navigation system, type-approved for paperless (electronic) navigation in accordance
with current rules and regulations. The additional functionality, including the possibility
of plotting optical bearings on the electronic chart, was implemented by Kongsberg
Defence and Aerospace (KDA), the supplier of the system to the Navy.

The K-Bridge system consists of five multifunction displays (MFD), where different
applications (ECDIS, Radar, Planning and Conning) can be selected according to the
navigator’s need for information (see Figure 28).

Figure 28: K-Bridge Integrated Bridge System. Illustration: The Royal Norwegian Navy/AIBN

28
Some parts of the system description in this section have been reproduced from the report of the Norwegian Navy’s
internal investigation team, who analysed data from the navigation system and integrated platform management system
(IPMS) on ‘HNoMS Helge Ingstad’ on 8 November 2018 (see section 1.15.1).

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Table 2 shows the applications that were implemented on HNoMS Helge Ingstad and
selected on the day of the accident:

Table 2: The K-Bridge Integrated Bridge System on HNoMS Helge Ingstad. Source: The
Norwegian Navy
MFD Applications implemented on Applications selected
HNoMS Helge Ingstad 08 November 2018
MFD 1 (normally the ECDIS and Radar, both X-band X-band radar
OOW’s operating station) and S-band.
MFD 2 (normally the ECDIS and Radar, both X-band S-band radar
OOWA’s operating and S-band
station)
MFD 3 (normally the ECDIS ECDIS
OOWA’s operating
station)
MFD 8 Planning (planning application – Planning
can also be used for voyage
monitoring)
MFD 9 Conning (overview showing Conning
information collected from
technical sensors)
MFD 16 Laptop with planning application Whether it was
that can be connected to the connected to the
network on the bridge. network on the bridge
is unknown.

1.9.3.2 DINA system

There is also a DINA29 system, which was not part of the delivery from KDA, but is
integrated with K-Bridge and distributes signals from the navigation system to the
Integrated Platform Management System (IPMS) and other technical systems. The DINA
system also transmits signals to separate displays showing navigation information
adapted for use by the various positions on board. For example, within the helmsman’s
field of vision is a separate display that is normally set to ‘Helmsman’, so that it shows
rudder angle and speed, among other things.

1.9.3.3 Data from the navigation system

The Navy’s internal investigation team has performed an analysis of data from the
navigation system and made a reconstruction of what was shown on the displays of MFD
1–3 (see sections 1.15.1 and 1.15.2).

1.9.3.4 Radar

HNoMS Helge Ingstad had two radars that were switched on and in use. The OOW had
master control of the X-band (3 cm) radar on MFD 1. The OOWA had master control of
the S-band (10 cm) radar on MFD 2.

29
DINA - Distribution of Navigation Signals

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The OOW had a video image of the S-band radar on the tactical console (on the starboard
side of MFD 1), without the possibility of changing any radar settings.

1.9.3.5 Electronic Chart Display and Information System (ECDIS)

On the day of the accident, the MFD 3 with Electronic Chart and Display Information
System (ECDIS) was used by the OOWT, among other things to plot bearings on the
electronic chart to verify the frigate’s position in relation to the chosen sensor.

The OOW also had the possibility of operating ECDIS on MFD 1, but was then unable to
operate the X-band radar at the same time.

According to the bridge manual, there were plans to show ECDIS on the conning display
at the centre of the bridge console. This would enable the OOW to make both radar and
ECDIS observations at the same time from his/her normal position on the bridge:

Furthermore, ECDIS software must be installed and a new licence purchased to

display ECDIS on the conning display, but this is something that must be
considered so as to be able to display 2xRadar and 2xECDIS in front of the
navigators at all times. Having an ECDIS at the centre, immediately in front of
the officer of the watch, will also be an advantage in connection with navex.

HNoMS Helge Ingstad did not have ECDIS installed on the conning display.

1.9.3.6 Automatic identification system (AIS)

HNoMS Helge Ingstad was equipped with an automatic identification system (AIS) of
the type Kongsberg Seatex AIS-200 Blue Force Warship AIS (WAIS). AIS-200 received
position and time data from GPS2.30 Three modes could be selected on the AIS: Mode 1
– standard AIS (active), mode 2 – receive only (passive) or mode 3 – encrypted AIS
(active).

1.9.3.7 Use of AIS

For operational reasons, it is sometimes desirable for military vessels not to disclose their
own position and data. Military regulations, and tactical factors that the CO of a naval
vessel choses to take into account, will always take precedence over rules issued under
the Norwegian Navy’s navigation regulations (SNP-500).

The AIBN has been informed that the operational framework plan from 2014, which was
developed after the security policy situation had changed, contained guidelines on
transmission that changed priorities relating to AIS. The naval vessels were then
increasingly engaged in operations in nearby areas, and there was a growing need for
keeping information about the movement of Norwegian vessel concealed. According to
the framework plan, AIS should, as a rule, be kept in passive mode (mode 2) from then
on, and only set to active mode (mode 1) when considered necessary for reasons of
navigational safety.

30
No information has been found to indicate that there was any form of interference in GPS signals in the Hjeltefjord on
8 November 2018.

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In 2018, the operational framework plan was updated without any mention of AIS.
Normal procedure was still to set the AIS in passive mode and to switch to active mode
when passing through areas of maritime traffic and if the navigator thought that other
vessels needed to observe the naval vessel more closely.

At the time of the accident, HNoMS Helge Ingstad was part of the NATO force SNMG1
(see section 1.9.7.5), and the instructions for the period in question specified that AIS was
to be kept in passive mode. On this particular voyage, HNoMS Helge Ingstad had last
transmitted AIS information when passing through Skatestraumen in the evening before
the accident. The AIS was in passive mode (mode 2) prior to and at the time of the
collision with Sola TS. It was set to active mode (mode 1) after the collision.

Warship AIS (mode 3) was not used during the voyage through the Hjeltefjord.

The Navy had no guidelines for the use of W-AIS when sailing in the service area of
Fedje VTS. W-AIS was a relatively new technology in the Navy in 2014, and the Navy
realised that equipping Fedje VTS with W-AIS could be helpful in reducing the need for
communication. Thus, they contacted the NCA, and the NCA acquired and installed W-
AIS at the VTS centre in 2015.

The investigation has shown that there was minimal communication about the use of W-
AIS in the service area of Fedje VTS after the spring of 2016. Based on the information
the AIBN has obtained, it was mostly unknown that Fedje VTS had W-AIS installed with
the correct encryption key. On 8 November 2018 there was still no agreed upon
procedures for the use of W-AIS between Navy vessels and Fedje VTS.

1.9.3.8 AIS symbols

In accordance with the functions described in the supplier’s manuals, all vessels with AIS
transmission within range were represented by symbols on the ECDIS and radar displays
on HNoMS Helge Ingstad. It has not been possible to reconstruct the AIS targets plotted
on MFD 1-3 during the voyage, because this information is not stored in the navigation
system, nor was the vessel equipped with a VDR.

The relevant symbols displayed for different objects are described in the bridge system
supplier’s AIS operator manual. A selection of symbols is shown in Table 3.

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Table 3: AIS symbols Source: K-Bridge Radar – Operator Manual, release 7.0.x
AIS symbol Meaning
By a sleeping AIS target is meant a target that is not being tracked. The
target’s orientation will vary with the vessel’s course.
A tracked AIS target. The symbol’s vector represents the vessel’s
speed and direction.
A tracked AIS target that has generated a CPA or TCPA alert.

Navigation object, landmark or buoy with AIS transponder.

Virtual navigation object. The symbol is shown on the radar or ECDIS

display only and does not represent the presence of any physical object.

1.9.3.9 Tracking of radar and AIS targets

Both radars had ARPA functionality enabling them to track radar echoes and calculate
course, speed, closest point of approach (CPA) and time to closest point of approach
(TCPA). To track an echo/radar target, it was necessary to place a marker manually on
top of the target on the display and press the ‘ACQ’ (acquire) button on the MFD.

If a given vessel is represented by both AIS and radar echo, both AIS and radar tracking
is possible. When the ‘ACQ’ button is pressed, the system will then choose between the
radar and AIS target according to which is closer to the marker’s position. The system
will then automatically continue to follow the target as long as it is within radar or AIS
range.

Both radars on HNoMS Helge Ingstad (MFD 1 and MFD 2) were set to give both sound
and text alerts if a tracked radar echo would pass HNoMS Helge Ingstad with CPA less
than 0.5 nm in the course of 6 minutes (TCPA). The AIS would generate similar alarms if
it was estimated that a tracked vessel would come closer than 0.5 nm in the course of 6
minutes. In both cases, alarms would only be generated if the vessels were being tracked.

Each MFD has a common alarm dialogue box (for both AIS and ARPA) where it is
possible to change the alarm limits for collision danger (CPA and TCPA) and proximity
violation. Any changes in the settings will apply to both AIS and ARPA targets, but only
for the MFD on which the change was made.

The ‘DATA’ function shown in Figure 29 is used to present data about a radar or AIS
target. By placing the marker on the target and pressing ‘DATA’, a pop-up window will
appear with information about the target’s name, bearings, distance, course, speed etc.
(see Figure 30). If a vessel is being tracked by both AIS and radar, both AIS and radar
information can be viewed simultaneously by expanding the window. AIS contacts do not
have to be targeted to display information when pressing ‘DATA’.

The supplier’s operator manual describes how to start AIS tracking, but does not include
any details on how long it takes to establish tracking.

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Figure 29: AIS target functions. Figure 30: By placing the marker on the target and pressing
Source: The Norwegian Navy ‘DATA’, a pop-up window will appear with information about
the target’s name, bearings, distance, course, speed etc.
Source: K-Bridge Radar – Operator Manual, release 7.0.x

1.9.3.10 Integration of radar, AIS and ECDIS

The OOWA had ECDIS on MFD 3 and could select radar or ECDIS (normally radar) on
MFD 2. AIS targets could be tracked on both ECDIS and radar.

The OOW could select radar or ECDIS on MFD 1. Radar was normally selected on MFD
1. According to the bridge manual, radar should be set up to display AIS contacts and
planned route. In the case of pure radar navigation, the shoreline in the electronic chart
(chart outline) and sea marks (aids to navigation) shall be presented. Both MFD 1 and
MFD 2 were set up as described. On changing from radar to ECDIS on MFD 1 and MFD
2, ARPA tracking would not be transferred. This is described in the manufacturer’s
operator manual, but not in the bridge manual. Changing the other way, from ECDIS to
radar, is described in the bridge manual:31

On changing back from ECDIS to RADAR on MFD 1 and MFD 2, the chart
overlay needs to be switched on and all AIS tracks need to be re-tracked (ARPA
tracks are maintained). This is not practical as it should be possible to switch
between the displays at frequent intervals.

1.9.3.11 Handling alerts

A single vessel being tracked will generate alarms for collision danger (CPA and TCPA)
and proximity violation. In total, a single vessel will generate six alarms if it is being
tracked using all available systems (MFD 1-3).

A total of 12 alarms for collision danger and proximity violation were generated between
03:47 and 04:01 during the night leading up to 8 November 2018. The vessels were
tracked on MFD 1 and 2. The final alarms that the bridge team had to handle were: a)
‘collision danger’ with ‘Seigrunn’ at 03:58:07 on MFD 1 and at 03:58:59 on MFD 2, the
latter being acknowledged at 03:59:09, and b) ‘proximity violation’ in relation to Silver
Firda at 04:00:20 on MFD 1 and at 04:00:21 on MFD 2, the latter being acknowledged at
04:00:31.

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V-200 Bridge Watch Guidelines, section V-210.03. Experience of K-Bridge

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On acknowledging an alarm, the person who does so shall state loudly and clearly which
alarm has been generated, for example: ‘Collision Danger on the southernmost of three
approaching vessels, planned passing distance xx’. This is to ensure information flow as
necessary between the OOW and the OOWA, at the same time as the information is also
conveyed to the CO if he/she is present on the bridge.32

The Navy has summed up how the alert system works as follows:

1. Alarms are indicated both optically and acoustically on all MFDs, regardless of which
MFD generates the alarm.

2. Individual settings are made on each MFD, among other things for Grounding,
Collision Danger and Proximity Violation.

3. Some alarms (for example the alerts for Grounding, Collision Danger and Proximity
Violation) can only be acknowledged on the MFD by which they were generated.

4. Alarms relating to routine monitoring cannot be acknowledged on ECDIS when the

latter is in Browse mode.

5. CPA/TCPA and Proximity alarms will only be generated for objects where tracking
has been established.

1.9.3.12 Automatic warning functions

Automatic tracking

HNoMS Helge Ingstad had a radar function for initiating automatic tracking of radar and
AIS targets (automatic acquisition of targets), but this function was not activated during
the voyage. The function for automatic target acquisition did not distinguish between AIS
and radar targets. The function was based on the radar operator indicating an area around
the vessel, for example a corridor of X nautical miles to either side of it and Y nautical
miles ahead. All radar echoes and AIS contacts within this area would then be tracked
automatically and the operator would be notified it the target came within a distance of
0.5 nautical miles of the vessel in the course of 6 minutes. The alarm limit can be
adjusted. The function tracks and issues warnings of all radar targets, regardless of
whether the radar signals were reflected from shore, vessels or other objects. On inshore
voyages, the function will to a large extent track and warn of targets without any
operational value, and, for that reason, it would normally be deactivated.

Sleeping target warnings

HNoMS Helge Ingstad also had an AIS function that could warn of sleeping AIS targets
(see Figure 31), that is AIS contacts not being tracked. The function would issue alerts for
sleeping AIS targets at the same CPA and TCPA as tracked AIS contacts. According to
the Navy, the function was normally deactivated on inshore voyages since the system
would otherwise generate many alarms of vessels alongside quays.

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P-200 Bridge Watch Procedure (REV 1606), section P-212

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Figure 31: The function for warnings about sleeping AIS targets is activated by ticking the box
‘Enable Collision Warning on Sleeping’. The settings for receiving warnings can also be changed.
Source: The Norwegian Navy

1.9.4 VHF radios

The bridge on HNoMS Helge Ingstad was fitted out with four VHF radios with built-in
loudspeakers and associated handsets (see Figure 26). One of the handsets, the one used
by the officer of the watch when HNoMS Helge Ingstad received the call from the pilot
on Sola TS, was located next to the IPMS on the starboard side of the bridge console,
approximately 1.5 metres from the radar display (MFD 1). The AIBN has been informed
that this VHF radio has been moved closer to MFD 1 on HNoMS Roald Amundsen and
HNoMS Otto Sverdrup, and that there had been plans to do the same on HNoMS Helge
Ingstad.

1.9.5 Navigation lights

During the night leading up to Thursday 8 November 2018, the navigation lights on
HNoMS Helge Ingstad were switched on. The frigate exhibited two white masthead
lights, sternlight and sidelights.

1.9.6 Voyage planning

As prescribed in the bridge manual (I-202.06.01) for the frigate squadron, a navigation
brief shall be carried out for relevant personnel before departure. This is a general brief
that, among other things, addresses the programme for the voyage, tides, weather, narrow
sounds, communications, navigation warnings, traffic and any other military activity. No
such brief was carried out for the inshore voyage in question. This voyage was planned
when the vessel already was under way.

The AIBN has received the vessel’s voyage plan. The planning of the voyage in question
was based on a standard route, it was planned and validated in ECDIS and approved by
the CO. Validation of the route took place in ECDIS the day before the voyage.
Validation involves checking the route against information available in the electronic
chart. According to the voyage plan for the area in question, the frigate’s planned speed
was 17 knots.

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ECDIS checks and notifies whether the planned route means that the vessel will pass any
shallow areas or geographical areas subject to limitations. If the system detects conflicts
between the planned route and the electronic chart data, it will give a warning (for
example ‘Grounding’). The navigator can change the route or enter a comment about why
the warnings occurred. These comments can either be linked to the route and
automatically give the navigator warnings (‘critical points’) or be entered as comments
relating to turns (‘waypoints’). The navigator needs to retrieve these comments in each
individual case to enable them to be presented on the screen.

The comments relating to the validated, approved route included warnings about fish
farms and shallows that would be passed. There was also a comment about notifying
Fedje VTS and listening to VHF channel 80, and a comment about changing to VHF
channel 71 when passing Jona light. None of these comments were entered as ‘critical
points’, and were therefore not automatically presented.

On the electronic chart, a ‘Safety Zone Sture’ was also marked around the Sture
Terminal. Figure 32 shows the safety zone as marked on the ECDIS on HNoMS Helge
Ingstad. HNoMS Helge Ingstad planned to pass this safety zone at a CPA of 700 m to the
safety zone. The planned route in this area, slightly to starboard in the fairway, was in
accordance with the Navy’s principles for voyages in inshore waters (SNP 500).

Figure 32: Map section showing the safety zone (marked with a pink broken line in the lower right
corner) around the Sture Terminal. Photo of the ECDIS/MFD 3 on HNoMS Helge Ingstad taken
after the accident. Photo: Crew member of HNoMS Helge Ingstad

The safety corridor for the voyage in question, on the basis of which the system had
validated the route, was set to 500 m on either side of the vessel. The safety corridor is
visible in ECDIS, but not on the radar, and the system would give alarm if the vessel left
this corridor.

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The passage through inshore waters was divided between the three OOWTs so that each
of them would get to navigate a route adapted to their level of experience. In addition, as
described in section 1.8.1.3, the CO and/or XO were always present on the bridge when
the vessel was to pass through demanding narrow waters and/or areas of maritime traffic,
and in conditions of poor visibility. The passage through the Hjeltefjord was not
considered particularly demanding, as the fairway is open and offers a good view all
around.

A captain’s night order book was not kept on ‘HNoMS Helge Ingstad’, but the
Commanding Officer (CO) gave instructions both during the planning phase and en route
(see section 1.2.1.1), which were communicated in connection with the officer of the
watch handovers. No joint review of the route (fairway review) was carried out with all
the navigators before the inshore voyage commenced. The relieving OOW and the
OOWT had both reviewed their part of the voyage route the night before the accident.

1.9.7 Frigate operation and sea training

1.9.7.1 General information

After it had been decided that the Navy would increase the number of operative frigates
from three to four HNoMS Helge Ingstad was taken out of a lay-up period and put into
operation in August 2016.

1.9.7.2 The sea training concept

The frigates are assessed every four years. The actual sea training period is of six months’
duration. The crew are evaluated as they follow a structured practical safety training path
in accordance with the Navy’s training concept OPUS. To start with, the focus is on
safety and basic skills, leading up to a final safety review. The frigates also train in
aspects of tactical warfare and handling damage situations and are subject to a general
evaluation33 by Flag Officer Sea Training (FOST), a UK body for evaluation of naval
units.

The Navy is the owner of the sea training programme and appoints a team to go on board
and evaluate the crew’s skills in different areas. The Navy’s Navigation Competence
Centre (NavKomp), represented by HNoMS Tordenskjold, tests the level of navigation
on board the vessel. NavKomp representatives normally spend two days on board
together with the bridge team to evaluate their performance. In addition to evaluating
navigation skills and teamwork on the bridge, they seek to observe each officer of the
watch when navigating with reduced sensors, at high speed, in daylight, darkness etc. The
bridge team and navigators are checked out and cleared by demonstrating that they have
attained the requisite level of skills, and general feedback is given to the vessel.

1.9.7.3 Safety review, HNoMS Helge Ingstad, 2016

NavKomp conducted an evaluation of navigation competence in connection with the

safety review of HNoMS Helge Ingstad. The following are relevant excerpts from the
summary, recommended priorities and proposals for further training mentioned in the
report (dated 20 October 2016):

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General evaluation: testing the entire vessel's capabilities against the requirements of a fully operational frigate.

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…Proposed further training:…- The OOW’s thoughts and intentions must be more
apparent. - Better knowledge of the structure of the navigation system. - Greater
attention to using binoculars (the whole bridge team) and use of radar in the
dark. This should be linked to the phases, of which the control phase is
particularly important. The lookout should learn to use the binoculars after every
turn – Read the COLREGS regularly and pay particular attention to the rules that
apply under different visibility conditions.

The overall conclusion from the safety review was that HNoMS Helge Ingstad had a
satisfactory level of sea training. The Navy has informed the AIBN that it is up to the CO
on each individual vessel to follow up the recommendations from the safety review.

1.9.7.4 Flag Officer Sea Training (FOST), 2017

In the FOST evaluation in 2017, HNoMS Helge Ingstad was awarded the grade ‘Very
satisfactory’. Among other thing, the vessel achieved a higher score than any Norwegian
vessel had previously achieved in tackling exercises with water ingress in multiple
compartments.

1.9.7.5 Participation in SNMG1 and Trident Juncture, 2018

HNoMS Helge Ingstad had joined the Standing NATO Maritime Group One (SNMG1) in
the Baltic Sea on 13 September 2018 and remained there until the start of the Trident
Juncture exercise off the Norwegian coast on 25 October 2018.

1.9.7.6 Bridge Resource Management (BRM) training

The following practice for BRM training was established in the Navy:

- All Norwegian naval officers have completed courses and training in BRM as part of
the STCW34 training required to obtain their certificates.

- Since 2001, the Navy (through NavKomp) has provided instruction in BRM and
engine resource management (ERM) and issued certificates of competence to cadets
at the Naval Academy, accredited by the Norwegian Maritime Authority.

- The Navy assumes that able seaman apprentices on board ‘HNoMS Helge Ingstad’
had been instructed in BRM as part of their STCW training in line with normal
practice, but lacks an overview of the facts.

- The Navy’s bridge teams are assessed in relation to BRM and teamwork during safety
reviews. According to the Navy, it is highly probable that individual members of the
bridge team on ‘HNoMS Helge Ingstad’ had been assessed while serving on board,
but it cannot be documented whether such an assessment of the practical teamwork of
the bridge team in question, had been carried out.

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STCW - Standards of Training, Certification and Watchkeeping for Seafarers

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1.10 The oil tanker Sola TS

1.10.1 General information

The tanker Sola TS (see Figure 33) is operated by the Greek business group Tsakos
Columbia Shipmanagement (TCM) S.A. The vessel was built at the Romanian shipyard
Daewoo Mangalia Heavy Industries (DMHI) and delivered to the owners in May 2017.

The vessel is a double hull tanker for carrying crude oil, with a length overall of 250 m,
breadth of 44 m and moulded depth of 21.2 m. The vessel’s deadweight tonnage is
112,948.8 tonnes. Sola TS is fitted out with a MAN-type main engine. Type D&T
6G60ME-C9.5 X1, with an output of 11820 kW and a fixed four-bladed propeller. The
vessel also has a spade rudder with a maximum rudder angle of 35°.

Sola TS is registered in Malta and classified by DNV-GL with the class notation +1A1 as
‘tanker for oil’. The vessel has also been assigned ice class ‘ICE-1B’.

Sola TS has 12 cargo tanks (6 on either side) with an aggregate volume of 123,933 m3,
and two slop tanks (one on either side). The vessel is double-hulled with the ballast tanks
located outside of the cargo tanks.

‘MT Sola TS’ was under a charter with Equinor, along with several other tankers from
TCM’s fleet.

Figure 33: The tanker Sola TS. Photo: Tsakos Columbia Shipmanagement S.A.

1.10.2 Bridge design and layout

Figure 34 shows the bridge on Sola TS.

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Figure 34: Bridge design of Sola TS. Illustration: Tsakos Columbia Shipmanagement S.A.

1.10.3 Navigational aids

1.10.3.1 Description

The vessel was fitted out with two approved ECDIS, in addition to one JMR-9230 S-band
radar and one JMR 9225 X-band radar. Sola TS carried normal radio equipment
consisting of two VHF radios in the forward bridge console and one VHF radio in the
GMDSS station at the aft end of the bridge.

Sola TS was equipped with AIS Class A transceivers. The vessel transmitted AIS signals
as normal, and AIS information from other vessels was automatically displayed on both
ECDIS displays. While sailing through the Hjeltefjord, the crew used AIS in addition to
radar with true trails and visual observations as sources of information about other
maritime traffic in the area.

1.10.3.2 Data from the navigation system

At 03:13, both radars on Sola TS were set to a range of 0.75 nm. The scale was set to
1:10,000 and 1:12,500, respectively, on the two displays showing ECDIS. This meant
that the instruments did not cover the area further south, where there were three
northbound vessels (Silver Firda, Vestbris and Seigrunn). The vessels approaching from
the north (HNoMS Helge Ingstad and Dr. No) were also not within the range scale of the
instruments on Sola TS at this point in time.

The tanker’s VDR recorded images of the ECDIS displays every 30 seconds and of the
radars every 15 seconds.

The range scale on the tanker’s S-band radar was increased to 1.5 nm at 03:27:05 and to
3.0 nm at 03:27:20. The range scale on the X-band radar was increased to 1.5 nm at

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03:27:33 and to 3 nm at 03:57:48. At 03:47:18 the S-band radar was off-centred. Variable
range marker (VRM) was switched on at 03:57:12 and placed on the echo of the frigate.

The scale of the tanker’s ECDIS 1 was changed to 1:12500 at 03:54:18. The scale of
ECDIS 2 was changed to 1:20000 at 03:54:07 and reduced to 1:12500 again at 03:54:38.
The scale of ECDIS 2 was changed to 1:20000 at 03:58:35 and was not rescaled before
the collision.

1.10.4 Navigation lights

1.10.4.1 Use of lights on Sola TS during the night leading up to 8 November 2018

When leaving the Sture Terminal, Sola TS exhibited the following lights: two masthead
lights, sidelights and sternlight. The tanker’s sidelights were located near the main deck
under the bridge wings. In addition, the vessel exhibited three red all-round lights in a
vertical line in the mast and on the roof of the bridge. Above the topmost of these lights,
the vessel displayed a flashing red light. Figure 35 shows the lights exhibited abaft
midship on Sola TS, with the same navigation lights as on the night of the accident, seen
from starboard during the observation voyage (see section 1.15.3).

According to the NCA, it has become established practice for tankers approaching and
leaving the Sture Terminal to exhibit the same lights as tankers calling on Mongstad:
three red all-round lights in a vertical line. Concerning the flashing red light, according to
the NCA, vessels carrying dangerous or polluting cargo are required to exhibit such lights
in Japanese waters. Normal practice in the rest of the world is to exhibit a fixed red all-
round light.

Figure 35: The lights exhibited abaft midship on Sola TS, viewed from the starboard side during
the observation voyage. Photo: The police

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1.10.4.2 Regulations concerning navigation lights

The Regulations of 01 December 1975 No 5 for preventing collisions at sea (COLREGs)

include provisions concerning navigation lights. Rule 20 b) is quoted below:

a) The Rules concerning lights shall be complied with from sunset to sunrise.
During such times no other lights shall be exhibited, except such lights as cannot
be mistaken for the lights specified in these Rules and do not impair their visibility
or distinctive character, or interfere with the keeping of a proper look-out.

1.10.5 Deck lighting

Sola TS had a total of 21 deck lights on the foredeck: 13 throwing the light forward and 8
throwing the light aft.

The forward-pointing deck lights were on when Sola TS left the quay at 03:36 (see Figure
36):

- On the bridge deck, approximately 21 m above the waterline, there were six deck
lights of the type Flood Light HPS.

- In the foremast, approximately 19.5 metres above the waterline, Sola TS carried three
LED lights. One of these light was mounted at the centreline and pointing forward.
The other two were mounted slightly to the side of and pointed at an angle of
approximately 45° from the centreline.

- In the starboard and port deck masts midship on Sola TS, were mounted a total of
four floodlights of the type Flood Light HPS, approximately 18.5 metres above the
waterline.

Figure 36: Simplified drawing of the forward-pointing deck lights that were lit on departure. Shortly
after departure, the four midship lights were turned off. Illustration: Tsakos Columbia
Shipmanagement S.A./AIBN

In addition, the vessel was equipped with the following aft-pointing deck lights: four
deck lights in the foremast and four in the starboard and port deck masts midship. The
latter lights had all been turned off just before 03:00.

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1.11 The Royal Norwegian Navy

1.11.1 In general

The Royal Norwegian Navy consists of the Naval Staff, the Fleet, the Coast Guard, the
naval bases, the Navy’s Medical Corps and the HNoMS Harald Hårfagre Basic Training
Establishment at Madla in Stavanger (see Figure 37). The Fleet is the Navy’s operative
force.

The Fleet and Coast Guard’s vessels are continually on assignment or preparing for
assignments – both in national territorial waters and abroad. The Fleet is a standing
combat organisation having the Navy’s materiel and coastal craft at its disposal, including
the Fridtjof Nansen-class frigates. The Fleet’s primary function is to be capable at all
times of defending Norway’s territorial waters by military means if necessary. The Fleet
shall ensure that its vessels and departments are provided with state-of-the-art equipment
and trained and motivated personnel.

Figure 37: Organisation chart of the Royal Norwegian Navy 2018. Illustration: The Royal
Norwegian Navy

1.11.2 Long-term plan for the defence sector

A new long-term plan for the defence sector ‘Combat force and sustainability’
(Proposition to the Storting No 151 S (2015-2016)), prepared by the Ministry of Defence,
was adopted by the Storting in November 2016. The plan entails a combination of
increased funding, continued rationalisation and structural changes. The following is
quoted from section 5.3 on the Navy:

(…) The current situation, with few crews, lack of maintenance and spare parts,
means that the vessels are not being put to optimum use. Priority is therefore
given to increasing the frigates’ level of activity in the upcoming four-year period.
Furthermore, the number of crews will be increased from 3.5 to 5, which means
that the Navy will be able to operate four frigates simultaneously. Among other
things, this will be achieved by rationalising the land-based staff and
administration to prioritise shipboard crews. (...)

1.11.3 Safety management and application of the Ship Safety and Security Act to vessels
belonging to the Armed Forces

The Act of 16 February 2007 No 9 relating to ship safety and security (the Ship Safety
and Security Act) Section 7 regulates the shipowners’ duty to establish, implement and

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further develop a safety management system. The Chief of the Royal Norwegian Navy
has been established as owner and the Chief of the Fleet as responsible for operations, in
accordance with Section 2 Owner and operationally responsible of the Regulations of 29
June 2017 No 1668 relating to the application of the Ship Safety and Security Act by the
Ministry of Defence’s subordinate agencies. The Regulations also regulate exemptions
from the Act for vessels belonging to or serving the Armed Forces. Among other things,
the Regulations state that the Armed Forces’ vessels are exempt from Sections 23
(Working hours) and Section 24 (Rest periods) of the Ship Safety and Security Act.

A directive on requirements for safety management in the Armed Forces (Direktiv – Krav
til sikkerhetsstyring i Forsvaret) contains generally applicable provisions on safety
management and attention to safety in the Armed Forces. Further operationalisation is
found in a set of instructions for the requirement for safety management in the Navy
(Instruks for krav til sikkerhetsstyring i Sjøforsvaret).

The Navy has interpreted the requirement for risk assessments in the Ship Safety and
Security Act in relation to its own safety regime and operations, and uses the risk
management tools in the operation of its vessels.

1.11.4 Education, competence and career path for navigators

1.11.4.1 Education

A navigator degree from the Norwegian Naval Academy is the start of the career path as
an operational officer on board the Navy’s vessels. Admission to the Armed Forces’
academies is granted by the Armed Forces’ admissions section (FOS) using a selection
scheme under which candidates assessed as being most fit for service are offered training
in the Armed Forces.

During the first 3.5 years at the Naval Academy, the students specialise in nautical
subjects, receiving theoretical instruction as well as extensive practical training on board
the Navy’s school ships. Compared with civilian maritime vocational and higher
education, the Naval Academy’s educational programmes provide for more practical
training on board school ships.

Naval navigation is traditionally more challenging than ordinary civil navigation as a

result of the operational requirements that apply to the vessels. The biggest differences
between instruction in civil navigation and military navigation largely relate to the use of
optical principles, basic use of the clock and logs, in addition to system understanding
and use of the navigation system without input from the GPS. Furthermore, while training
and instruction in the use of pelorus devices is generally not offered at civil navigation
schools, these are essential aids in military navigation. Navigational warfare is another
subject not taught at civilian schools.

Following the restructuring of the Navy in 2016, vessel-specific courses are largely left to
the vessels in the form of on-the-job-training.

1.11.4.2 Practice and career path

According to the Navy’s career and service plan, dated 7 July 2017, there will normally
be greater focus on technical skills early on in a person’s career, while this is less
prominent at a later stage – overall understanding and management become more

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important in higher-ranked officer positions. On Fridtjof Nansen-class frigates, officers

start as trainees in the department corresponding to their field of specialisation, with the
focus on gaining ‘clearance’ for their various functions. On being cleared, the candidate
will normally advance to the next level in his or her section.

In the career map for officers on frigates, one of the positions is designated ‘Navigation
Officer 1-3’. The recommended minimum period of service in this position is set to 2-4
years.

During the first year of practical training as navigation officer on board an operational
naval vessel, the trainee is a novice in navigational skills. In that year, much time will be
spent on becoming familiar with the vessel’s procedures and on translating the theoretical
learning acquired at the Naval Academy into practical navigation and operation.

After a year of practical training, the trainee will usually be familiar with the relevant
procedures and have acquired an understanding of his/her function on board. The
candidate will also have tried his/her hand at using all navigational aids. Depending on
the vessel’s sailing pattern, as navigator, the trainee will also get some experience of
inshore voyages as well as navigation in open waters.

The career path from navigation officer to CO is normally completed in about 12–15
years, where it is natural for officers to serve in other departments of the Armed Forces
along the way.

1.11.4.3 Qualification and clearance of bridge officer of the watch

The process for clearing bridge officers of the watch differs between the different types
of vessels. On some vessel types, the clearance process is based on own courses and
checkouts under the auspices of the operating organisation. On frigates, it is the CO who
decides at what time a navigation officer has gained a sufficient level of competence to be
cleared as officer of the watch. On board a frigate, it normally takes 1–2 years to receive
training and clearance as officer of the watch in accordance with the checklists in the
manuals.

Based on the information the AIBN has received through interviews with representatives
of the Navy’s navigational competence environments, an officer should have 3–4 years’
experience in order to be considered an experienced officer of the watch. A cleared
officer of the watch should have 2–4 years’ experience before being charged with training
other navigators.

1.11.4.4 Practical experience and certificates

On completing their education, candidates must have 360 days of service on board before
they can be issued with a first certificate as Deck Officer Class 4/3 (D4/D3). All working
hours are reckoned to be hours of sea duty, whether at sea, alongside or on guard duty.

When a first certificate has been issued, service time is earned as a factor of 0.8 of the
number of days the deck officer holds the position on board. To be issued with a Deck
Officer Class 2 certificate, the candidate must have completed 24 months of service on
board (i.e. 30 months in the position on board) after the date of issue of the D3/D4
certificate. To be issued with a D1 certificate, the candidate must have completed 36
months of service on board (i.e. 45 months in the position on board) after the date of issue

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of the D3/D4 certificate. One month is reckoned as 30 days. Service time is recorded by
the Navy Staff (SST/P) at Haakonsvern.

To become an officer of the watch on a Fridtjof Nansen-class frigate, a Deck Officer

Class 4 (D4) certificate or better is required.

1.11.5 Job descriptions

1.11.5.1 Commanding Officer

According to the job description for captains on Fridtjof Nansen-class frigates, the CO’s
duties and responsibilities are as follows:

The CO is responsible for all operation of the vessel and for training and
education of subordinate personnel. The CO is responsible for financial
dispositions, control and follow-up in accordance with allocated budgets, and for
applicable directives and regulations.

The CO on board is responsible for qualification and clearance of new officers of the
watch.

The following is stated the Navy’s Service Manual SAP-1(D), Chapter 3 ‘The CO’,
section 335:

1: The CO shall seek to arrange the service so as to motivate and engage interest,
develop a feeling of responsibility, the will and strength to act independently…
4: Young officers should be given as much independence as possible to carry out
some part of the service and lead drills and work operations so that they assume
responsibility and are afforded the chance to exercise own judgement and act of
their own accord.

1.11.5.2 Navigation Officer 1

According to the job description for Navigation Officer 1 on Fridtjof Nansen-class

frigates, the officer is charged with the following duties and responsibilities:

The position as Navigation Officer 1 on board a Fridtjof Nansen-class entails

responsibility for passage planning in cooperation with the Executive Officer
(XO) and Operations Officer. Arranging navigation training, including
instruction for students and own crews. Navigation Officer 1 shall ensure that all
personnel standing watch on the bridge have received necessary training.
Assisting the CO with navigational information. Watch standing in accordance
with the vessel’s watch bill.

1.11.6 Regulations for exercising navigation on the Navy’s vessels (SNP-500)

These regulations on practical navigation, issued in 2013, apply to the whole Navy. The
purpose is described as follows:

The document describes how the Navy’s traditional principles for inshore navigation
shall be upheld when using modern electronic aids such as electronic charts, global

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positioning systems and integrated bridge systems. The purpose is to promote safe
navigation and support the vessels’ work on navigation.

SNP-500 is an official approved document forming the basis for the governing bridge
service documents (bridge manual) for Fridtjof Nansen-class frigates. NavKomp is
responsible for the content.

Optical navigation is defined in the regulations (p. 8) as ‘navigation without the use of
electronic aids’. The regulations (p. 9) state that ‘The optical principles and techniques
form the basis for navigation in the Navy.’

The reason why the Navy continues to rely on optical navigation in a time when
electronic navigational aids are extensively used both in civil and military navigation is
stated as follows (p. 9):

The Navy wants to uphold the principles and techniques that form the basis for
optical navigation for reasons of safety and security, for tactical reasons and for
educational reasons. Developments in technology have introduced electronic aids,
however, that affect the navigator’s working environment and tasks. One reason for
this is that vessel steering and positioning have largely been automated through the
use of electronic charts, automatic steering and global positioning systems. By using
traditional principles and techniques for optical navigation in combination with
more recent electronic aids, the Navy will maintain the skills of navigators and at the
same time be capable of evaluating the quality of the data presented by electronic
aids.

This is why all navigators receive practical training in optical navigation on board the
vessels as part of the process of being cleared for the officer of the watch position.

In order to check the position that is being presented by the navigation system at any
time, the navigators use different modes, or methods of sailing the vessel (p. 10)

It will always be one of the following three modes:

• Optical mode
• Radar mode
• A combination of the two

The following concerns principles for voyage planning (p.32):

All route planning is carried out with all available aids that are relevant to the
voyage and the waters. During the voyage itself, both optical and radar control
methods can be used. Most voyages are carried out in optical control mode,
which is why this is the starting point for route planning.
When the accident occurred, training in optical control principles was being conducted.
The following is reproduced from section 3.1.2.1 Rule – Use of control methods on a
voyage: ‘In the course of a bridge watch, the vessel’s position should be checked and
training should be provided in available methods of checking the vessel’s position.’

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1.11.7 The bridge manual

1.11.7.1 Introduction

I-200 Instruks for brotjenesten (‘Bridge service instructions’), V-200 Veiledning for
brotjenesten (‘Bridge service guidelines’), P-200 Prosedyrer for brotjenesten (‘Bridge
service procedures’) and L-200 Sjekklister for brotjenesten (‘Bridge service checklists’)
for Fridtjof Nansen-class frigates were the governing bridge service documents (the
bridge manual) that applied to HNoMS Helge Ingstad at the time of the accident. SNP-
500 (see section 1.11.6) forms the basis for these documents.

1.11.7.2 The bridge team’s tasks and responsibilities

According to I-202.03, the officer of the watch (OOW) reports directly to the CO and is
in command of the vessel on behalf of the CO. This applies unless the OOW in the
operations room is in command. It also applies when the vessel is being navigated by the
OOWT.

The following is reproduced from I-202.06 on bridge service execution:

06.03 Prioritisation and assessment

Safe navigation shall always be emphasised and, during peacetime operations,
always take priority over other considerations. The officer of the watch shall
navigate safely and effectively by fully utilising available aids at all times. The
question of ‘what if’ shall be a recurring theme in the continuous assessments
made by the officer of the watch when serving on the bridge.

The officer of the watch trainee (OOWT) is described in I-203. The following is stated in
the general part of the OOWT instructions (I-203.01):

The training of new navigators is a continuous process, where the purpose of the
training is to instil in the candidates necessary knowledge about the officer of the
watch’s duties and responsibilities, the vessel’s manoeuvring characteristics,
equipment on the bridge, safety rules relating to the use of weapons and special
exercises, the vessel’s organisation, good work routines and correct attitudes. As
a rule, a plan for the watch shall be in place for the training to be as effective as
possible, and the officer responsible for the training shall have perused the plan
for officer of the watch clearance. The officer of the watch in question shall also
have a clear understanding of the training goals for the watch.

The following three points are reproduced from the specifying part of the OOWT
instructions (I-203.02):

c. …The OOW shall know the vessel’s positions at all times, for example by
visually observing GPS pos fix on his/her console so that it can be compared with
the position calculated by the OOWT.
e. Proper preparation is a precondition for serving as OOWT. The OOWT is
expected to prepare the watch in the same way as the OOW, including to
participate in all relevant briefs and read signals of relevance to the watch.
f. The OOWT shall talk while negotiating the fairway/performing manoeuvres, so
that the OOW/CO is informed about the assessments made at all times. Any doubt

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on the part of the OOWT shall be communicated to the OOW and acted on as
necessary.
g. The OOWT is expected to demonstrate willingness to learn, inquisitiveness and
active information seeking.

The primary task of the officer of the watch assistant (OOWA) is defined as follows in I-
204.01:

The officer of the watch assistant shall assist the officer of the watch with the
navigation. The officer of the watch assistant’s position is on the port side of the
bridge. His primary task is to operate MFD 3, where he is responsible for
monitoring and correcting the voyage by continually informing the officer of the
watch about time and distance to turn, next course, headings, turn objects,
passing distances etc. in accordance with applicable procedures. His secondary
task is to operate and monitor MFD 2 with the emphasis on information about
other vessels, including to help with surface image construction in the operations
room.

The manual does not contain any formal or specific requirements for the OOWA’s
competence and training in relation to the execution of primary and secondary tasks.

The lookout’s duties are described as follows in I-208:

All vessels have a duty to maintain active lookout in order to be able to detect and
identify any vessels, floating objects, navigational marks and lights at the earliest
possible time, at the same time as visual contributions to image
construction/identification are important on a warship.
The lookout is required to be constantly vigilant. The lookout is responsible for
immediately reporting any observations of importance within his/her range of
vision to the officer of the watch, who will communicate any relevant information
to the operations room.
…
If only one lookout is present on the bridge, she/he shall be positioned on the
starboard side.

The instructions do not mention the use of binoculars specifically. The reason why the
starboard lookout position must be manned is to monitor any need to give way to
starboard, and the starboard lookout is also tasked with assisting to launch the dinghy in a
man-overboard situation.

The helmsman was not responsible for maintaining lookout or reporting about vessels.
The helmsman’s duties and responsibilities are described as follows in I-209.01:

A helmsman shall be available on the bridge at all times, alternatively as one of

two lookouts when automatic steering is used. His task is to stand at the wheel,
and to man the emergency steering system should this be necessary.

The division of responsibility between the helmsman and navigators is described as

follow (I-209.02):

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The helmsman is part of the bridge watch team and reports directly to the officer
of the watch. He shall be present on the bridge and ready to take the wheel all
times, including when automatic steering is used. Under normal circumstances,
the vessel will be navigated by either an officer of the watch or an officer of the
watch trainee, who will issue rudder orders and permit the helmsman to be
relieved. In some cases, rudder orders may be issued directly by the officer of the
watch, the XO or the CO, according to what they consider necessary. The
helmsman shall always comply with orders received from these three persons.

1.11.7.3 Control of position using radar and optical aids

During the night leading up to 8 November 2018, HNoMS Helge Ingstad was being
navigated in a mode known as ‘electronic positioning with combined optical and radar
control’, which in V-230.04 is described as follows:

- This mode utilises all available equipment to perform an overall and at all times
most appropriate control of the voyage.
- If optical control is not possible on account of visibility conditions, electronic
positioning with radar control will apply.

When electronic positioning is active, the vessels real-time position is transmitted from
the GPS via the inertial navigation system (INS) to the electronic chart (ECDIS), and
updated every second.

Radar control of the vessel’s position uses the chart outline on the radar display. This is
described in V-210.09:

Radar charts: The chart outline and aids to navigation shall be displayed. The
purpose of this is to quickly ascertain whether the GPS pos tallies with the radar
image and to help to identify vessels versus fixed objects. As long as the chart
outline is in accordance with the shore contours on the radar, and the vessel is
travelling along a validated route displayed on the radar, it is unnecessary to use
parallel indexes.

V-230.03 specifies the following principles for optical control: Steering towards objects
(bow and stern bearings, turn bearings in relation to objects, cross bearings, navigation by
half lines, four-line bearings and displaced lines of position (LOP). The bridge manual
goes on to describe how radar control shall be carried out using parallel index techniques,
turn by index or bow distance, positioning by multiple radar distances and/or radar
bearings and control of chart outlines on the radar display.

1.11.7.4 Control of traffic situation

The control methods listed for optical and radar control are all based on principles for
determining the vessel’s own position. With respect to detecting other vessels and
avoiding proximity situations, the bridge manual I-202.06.04 states that proper lookout
must be kept at all times regardless of waters and conditions. At least one navigator
(OOW, OOWT or OOWA35) shall look out at all times.

35
Previously, in connection with ECDIS being phased in on board the Fridtjof Nansen-class frigates, the OOWA
function was manned by navigators.

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V-202.04 Methodology for radarnavex (radar navigation exercise) describes that in order
to divide the tasks between the two radars, it is expedient that the radar dedicated to the
OOWA uses a range scale of 3 nm or more for early detection of other maritime traffic.
The OOW mainly works in range scales of 3 nm and lower. When sailing in narrow
fairways and in connection with vessels passing, use of the lowest possible range scales is
expected in order to get as accurate a picture as possible of the closest dangers.

1.11.7.5 The combat information centre

The combat information centre (CIC), which possess capabilities and expertise that can
help to discover and identify contacts on demand from the bridge, was not part of the
navigation team during the current voyage. Besides one general comment, the bridge
manual does not mention how the CIC can support navigation. The AIBN has understood
that such support is to a limited extent trained and practiced. The AIBN does not consider
the CIC further in this part of the investigation.

1.11.7.6 Cooperation and communication

V-201.02 contains a general observation that concerns everybody on the bridge:

It is important that everybody on bridge watch is aware of the responsibility for

safety and security that the bridge watch entails, and that the bridge crew work
well as a team. The threshold for alerting if anything is observed or otherwise
perceived to be wrong shall be low, and the officer of the watch shall motivate
and involve his crew to ensure that all crew members perform their best within
their respective areas of responsibility.

The following is reproduced from P-202.02.04 concerning the officer of the watch
assistant:

…Orders issued and information exchanged between the officer of the watch and
the assistant shall be brief, concise, loud and clear. Loose assumptions and the
use of relative parameters should be avoided. Information that is clearly not
relevant or clearly known to the officer of the watch shall not be stated. The
information shall nonetheless be conveyed if in doubt.
Everybody with navigational tasks works in a team, that can only function
optimally if everybody is aware of their roles and duties, follows procedures,
shows initiative and where all members of the bridge team know each other well.

Communication between members of the bridge watch team shall be in accordance with
procedures. Closed-loop communication shall be used, i.e. orders shall be issued by the
officer of the watch and acknowledged by the helmsman, who then reports on having
executed the order and has this acknowledged by the officer of the watch.

The procedures also state that the noise level on the bridge should not be so high that the
officer of the watch must shout to be heard by the lookout and helmsman.

I-201.04.03 clarifies the following as a general rule:

The navigation officers are responsible for ensuring that own crews on board the
vessel are informed about the applicable revision of the regulations and for ensuring
that the regulations are complied with in the performance of their service.

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1.11.7.7 Watch handovers

L-200 in the bridge manual includes a checklist for handovers between officers of the
watch (L-201-2 Sjekkliste – Vaktsjefoverlevering), which is to be completed before the
relieving officer arrives on the bridge:

The relieving officer reviews the list while acquiring night vision/preparing the
watch, and asks questions if anything in the handover is unclear. This reduces the
time that the handover takes, at the same time as the officer of the watch being
relieved is not prevented from focusing on the vessel’s safe passage when nearing
the end of his or her watch.

The Sjekkliste – Vaktsjefoverlevering mainly contains a summary of the vessel’s

configuration, including the status of machinery, vessels and navigation systems. Aspects
related to navigation and traffic situations are discussed between the officers of the watch
in the handover.

L-200 also includes a checklist for handovers between officer of the watch assistants (L-
203 Sjekkliste – Vaktsjef assistent overlevering).

1.11.8 Working environment, working hours and rest periods

1.11.8.1 Background

Personnel serving in the Navy are exempt from the Ship Safety and Security Act’s
provisions on working hours and rest periods pursuant to separate exemption regulations
(see section 1.11.3). Based on the above, the Ministry of Defence (MoD) and the Fleet
(Navy) shall adopt separate provisions to ensure that requirements for rest periods as
provided for in laws and regulations are met overall.

1.11.8.2 Procedure for rest and restitution in the Navy

Excerpt from the procedure on rest and restitution in the Navy (Prosedyre for hvile og
restitusjon i Marinen), dated 2 October 2016:

2.1 The CO’s responsibility:

The Navy is engaged in force production for the purpose of being able to deliver
combat force in situations of war or crisis. Force production requires endurance
training. This will affect the possibility of having optimum hours of rest. The CO
is responsible for the safe and secure operation of the vessel. This means that the
CO must continually assess the risk associated with inadequate rest, and take
action when the risk becomes excessive. The need for rest hours must be
considered in relation to the nature of the work. Special focus must be given to
sleep deprivation in personnel performing critical functions.
2.2 The responsibility of each individual:
Many individual circumstances have an impact on sleep deprivation. It is
therefore difficult for the CO to assess the risk unless somebody blows the whistle.
Those who feel the effects of sleep deprivation therefore have a special
responsibility to notify their superiors.
(…)

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1.11.8.3 Protection provisions in the Navy

The work on regulating how the Ship Safety and Security Act should be applied to the
Armed Forces has been going on for a period of more than 11 years, from work on the
new Regulations was initiated in 2006 until they were adopted in 2017. Internal rules and
a system of supervision have not yet been established or implemented for ships used by
Ministry of Defence’s subordinate agencies as described in Sections 4 and 5 of the
Regulations relating to the application of the Ship Safety and Security Act by the
Ministry of Defence’s subordinate agencies.

The work on the regulations for ship safety includes rules on working hours and rest
periods. Protective provisions for sea-going personnel in the Navy, to replace Section 1 of
the exemption regulations, limited to considering provisions to make up for the special
exemption provided for in Sections 23 and 24 of the Ship Safety and Security Act, are
part of the requirements included in this work.
The Ministry of Defence is responsible for drawing up such protection rules. On the
Naval Staff’s initiative, the Navy’s competence environments became involved in this
work and the Navy was assigned the task of preparing a set of draft provisions to meet the
requirements set out in the Regulations to the Ship Safety and Security Act. The draft
internal rules were made available by the Navy on 30 September 2019.

1.11.9 Lean manning concept (LMC)

The Fridtjof Nansen-class frigates were built with a view to being operational with a
minimum crew, approximately half the crew needed on comparable vessels. This concept
is known as the lean manning concept (LMC).

The following is reproduced from section 1.5 of the crewing plan 3.0, dated 1 July 2016:

LMC entails optimisation of the crew with a view to performing the primary tasks
on board and does not include redundancy. Instead, many positions cover several
functions and are assigned additional tasks.
This multi-functionality, combined with marginal crewing, means that the vessel’s
operational combat capacity is directly based on qualitative as well as
quantitative personnel production, where motivation, attitudes, and levels of
competence and experience are all critical factors. Multi-functionality places
strict requirements on education, instruction and training, and entails a high
workload and extensive effort. This may mean that individuals may be pushed to
the limits of their capabilities. The concept is therefore basically neither
personnel-friendly nor family-friendly.

1.11.10 Voyage Data Recorder (VDR) on the Navy’s vessels

In 2009, the Ministry of Defence approved a procurement solution for Project (P6005)
Voyage Data Recorder (VDR) for the purpose of installing S-VDR/VDRs on several of
the Navy’s vessels. The following requirements were described in the assignment:

Under the Ship Safety and Security Act, all vessels are required to be able to
present data after an incident at sea. The work on implementing the Ship Safety
and Security Act and its regulations in the Navy is based on compliance with both
statutory requirements and the intentions of the Act. This will help to prevent any

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lack of clarity in connection with the exercises and drills the Navy conducts
nationally or internationally, regarding ship safety and security, and form a basis
whereby the Navy can be treated on a par with other maritime activity.

The following year, in 2010, the Armed Forces were awarded the assignment, with the
Ministry of Defence as project owner, the Norwegian Defence Logistics Organisation
(NDLO) as project manager and the Navy as the party responsible for implementation.
As it turned out, work on the procurement never started, and the project was eventually
terminated without VDRs having been installed on any vessels.

After an accident involving one of the Navy’s vessels in 2013, the Armed Forces
appointed an internal investigation board. One of the factors highlighted by the head of
the Armed Forces’ operative headquarters, the investigating authority at the time, in the
summary report (2015) to the Defence Staff, was the need for VDRs on the Navy’s
vessels:

Had VDR data from the incident been available, the [] would have had access to
unique data to document the sequence of events more exactly, and to better
understand the situation on board the [vessel]

The following recommendation was issued by the head of the Armed Forces’ operative
headquarters:

The investigating authority recommends that the Ministry of Defence, in

cooperation with the Armed Forces, consider the possibility of installing and
using VDR on various military vessels, for the purpose of improving the follow-up
of safety on board after accidents and incidents.

1.12 The shipping company Tsakos Columbia Shipmanagement (TCM) S.A.

1.12.1 General information

Tsakos Columbia Shipmanagement (TCM) S.A. was formed in 2010 and has offices in
Athens in Greece. TCM is responsible for technical and other operations and for crewing
a varied fleet of approximately 80 vessels.

1.12.2 Navigation manual

TCM has prepared a ‘Navigation Procedures Manual’ (NPM), with guidelines for how its
vessels are to be navigated. Relevant parts of the manual are cited below.

1.12.2.1 NPM Section NPM-01: Navigation Procedures

The purpose of the procedure is to specify safe practices and to ensure that necessary
precautions are observed by the master and officers on bridge watch for the vessel’s safe
navigation. The section on responsibility states, among other things, that the master shall
remain on the bridge when the vessel is approaching/leaving port and when in the vicinity
of other vessels. The master shall ensure that the bridge is manned as necessary and that a
safe distance to other vessels in the vicinity is maintained at all times.

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Chapter 3 of the procedure describes ‘Pre-sailing preparations’, intended to ensure that all
necessary checks and preparations on the bridge are carried out before departure. The
pre-sailing preparations include drawing up a passage plan.

1.12.2.2 NPM Section NPM-02: Voyage planning

The purpose of this procedure is to prepare a pre-sailing plan, which shall provide for the
safety of vessel, crew and cargo and for environmental protection during the whole
passage.

The plan is prepared by the vessel’s navigation officer and approved by the master. Prior
to departure, the master shall have discussed the whole plan with the rest of the bridge
team. All navigation officers must review and sign the plan to acknowledge that they
have read and understood it.

The plan for the voyage from the Sture Terminal to Tetney in the UK was described
using ‘Form NAV-009A: Passage Plan’. Under ‘Special navigation safety requirements’,
the navigation officer had, among other things, drawn attention to there being a high
danger of collision on account of dense vessel traffic in the area they were passing after
leaving the Sture Terminal.

1.12.2.3 NPM Section NPM-03: Bridge Watchkeeping

The purpose of this procedure is to set out requirements for an effective bridge
organisation and watchkeeping, in order to ensure safe navigation of the vessel. It also
describes how the bridge on all TCM’s vessels is organised as a team so as to safeguard
against and correct possible errors. Relevant parts of the procedure are described below.

While sailing, the bridge officer of the watch (OOW) shall monitor and be fully aware at
all times of the vessel’s position, and the position, course and CPA of other vessels in the
vicinity.

Section 3.1 of the procedure entitled ‘Bridge Team Management’ (BTM) points out the
following, among other things:

BTM refers to the management of the human resources available to the Master (OOW,
helmsman, lookout, duty engine officer etc.) and how to ensure that all members
contribute to the goal of a safe and efficient voyage. The primary goal of BTM is to
eliminate ‘one-person errors’.

There must be a free exchange of information between the bridge team members. The
officer in command (conning officer) must keep the other bridge team members apprised
of intended manoeuvres, as fully as the circumstances permit. It is important to keep
bridge team members up to date with a developing situation.

Even if not recognised as part of the watch team, the pilot plays an important role on the
bridge, and it is the responsibility of the bridge watch team to assist the pilot to work
within the team.

According to the manual, the circumstances when sailing out from the Sture Terminal
indicated that the bridge should be manned in accordance with ‘Elevated Condition 2’.
The bridge team shall consist of the master (or chief mate), the navigation officer of the

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watch, one able seaman at the helm and one able seaman or ordinary seaman as lookout.
The navigating officer’s primary responsibility is collision avoidance and monitoring the
vessel’s position. Among other things, the navigating officer shall operate the
radar/ARPA and other navigational aids, and plot all targets within a range, as ordered by
the master.

Section 3.8 of the manual addresses ‘Watchkeeping controls at sea’ and points out that
the OOW must not rely solely on one source to determine whether there is a risk of
collision, but use the ARPA in conjunction with visual bearings, and any other means, to
establish if a risk of collision exists. Furthermore, reliance solely on AIS information
displayed on the ECDIS as an aid to collision avoidance must be avoided. AIS
information must be compared with the information from the ARPA, radar or visual
observations.

1.12.2.4 NPM Section NPM-03 Chapter 4: Pilotage

Section NPM-03 of the manual also contains a separate chapter on pilotage (Chapter 4).
The master retains full responsibility for the safety of the vessel, while the pilot assists by
providing navigational advice.

The master-pilot exchange (MPX) is an important tool for including the pilot as a
resource for the bridge team. MPX is intended to inform the pilot about vessel particulars,
including draft, engines, navigational aids, manoeuvring characteristics and any special
conditions or characteristics that may affect the pilot’s ability to understand how the
vessel should be handled. The goal of the MPX is to establish a rapport with the pilot and
to agree on the plan for the transit, in order to ensure that everyone responsible for
navigating the vessel shares the same plan.

The procedure also points out that English should always be established as the common
communication language between the pilot and the bridge team, and that English shall be
used for all internal and external exchange of information about the vessel’s operations.

1.12.3 The use of deck lights

The owners had established procedures specifically relating to the use of deck lights with
regards to the crew’s safety while working on deck. The use of deck lights is dependent
on the operation of the vessel at the time and at the discretion of the master or the officer
of the watch.

The owners refer to the Code of Safe Working Practices for Merchant Seafarers
(COSWP) published by the Maritime and Coastguard Agency (MCA) of the UK,
Sections 26.3.6 and 31.3.3. Chapter 26.3.6 points out, among other things, that the work
areas during mooring operations must be adequately lit when work is done in the dark
part of the day. Chapter 31.3.3 points out that at nighttime there should be lighting in
areas where work is going on. It is further pointed out that this lighting should not affect
the prescribed navigation lights.

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1.13 The Norwegian Coastal Administration (NCA), VTS centres and pilot services

1.13.1 The NCA

The NCA is a national agency for maritime transport, maritime safety and acute pollution
response. The NCA is headed by the Director General and the head office is the agency’s
highest governing body. The regions perform operative and common tasks on behalf of
the Director General. The NCA has nine operating units: five regions, the shipping
company, the Pilot Service, the Centre for Emergency Response and the head office (see
Figure 38).

Figure 38: The NCA’s organisation chart. Illustration: The NCA

1.13.2 Vessel Traffic Services

1.13.2.1 General information

The Vessel Traffic Service is an international service, which, in Norway, is operated by

the NCA to improve safety at sea and protect the coastal environment. The NCA’s five
VTS centres monitor and organise maritime traffic 24/7 in defined service areas along the
Norwegian coast. Their work is regulated by the Regulations of 23 September 2015 No
1094 relating to use of vessel traffic service areas and use of specific waters (the
Maritime Traffic Regulations).

1.13.2.2 Regulations related to communication and duty to listen

Section 7. in the Maritime Traffic Regulations concerning Communication in the VTS

area:

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Communication between a vessel traffic service centre and a vessel must take
place over the VTS centre's VHF working channels. Communication between
vessels concerning passing or other coordination of voyages must take place over
the VTS centres' VHF working channels. The master of the vessel or whoever is in
command in his place must be able to communicate in a Scandinavian language
or English if the vessel is not using a pilot. Vessels under military command may
communicate with the VTS centre via mobile telephone when necessary.
Section 11. in the Maritime Traffic Regulations concerning Duty to listen and duty of
disclosure:

Vessels that use a VTS area have a duty to listen to the VTS centre's VHF working
channels. Vessels that use a VTS area must inform the VTS centre about any
matters that may be of significance to safe passage and efficient traffic flow,
including that the vessel is departing from the dock or anchorage site or is making
changes to its cleared sailing route.
1.13.2.3 The tasks of the VTS centres

The VTS centres are tasked with the following:

- traffic monitoring with the aid of monitoring and communication systems such as
radar, land-based and satellite-based AIS, VHF radios, meteorological sensors and
video cameras;

- granting sailing permission to vessels before they enter the VTS area and before they
leave port;

- providing information and organising maritime traffic;

- intervening to enforce the Maritime Traffic Regulations as necessary;

- monitoring and immediately contacting vessels on suspecting engine problems,

incorrect course or anything else that is out of the ordinary;

- summoning, issuing orders and providing assistance to vessels as necessary;

- being part of the NCA’s first-line acute pollution response organisation.

1.13.2.4 The services of the VTS centres

The Vessel Traffic Service (VTS) offers three types of services, based on international
regulations and recommendations36:

1. Information Service (INS)

This service shall provide important information at the right time to support nautical
decision-making processes on board. A vessel may request information, and the VTS
centre may provide unsolicited information and request clarification from the vessel
as required.

36
http://www.kystverket.no/Maritime-tjenester/Sjotrafikkovervaking/VTS-tjenester/ [read 22 October 2019].

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2. Navigation Assistance Service (NAS)

Navigation assistance is established either on the request of the vessel or when the
VTS operator observes irregular navigation and deems it necessary to intervene. The
vessel and the VTS centre will agree on when the navigation assistance service starts
and stops. This service entails close assistance to the vessel in question.

3. Traffic Organisation Service (TOS)

TOS is exercised to prevent the occurrence of dangerous traffic situations and to
contribute to the safe and efficient management of shipping traffic in the service areas
of the VTS. The service includes operational organization and planning of ship
movements and is particularly relevant when there is high traffic density. Vessels of a
certain size must apply for a permit before sailing or anchoring in the service areas of
the VTS and must further report before entering the VTS area or before departure
from the quay or anchorage.

Appendix C contains excerpts from the instructions for these three services for Fedje
VTS.

1.13.2.5 Competence requirements for VTS operators

To be employed as a VTS operator by the NCA, the candidate must have a maritime
nautical background, including holding a Deck Officer Class 2 (D2) certificate, and have
passed the Deck Officer Class 1 (D1) exams. The appointed candidates must complete
various work psychology tests, conduct a common central agency training in addition to a
local training at the VTS centre where they are to work. They will then be authorised to
serve as VTS operators at the VTS centre in question. The VTS operators attend refresher
courses and are recertified every five years.

1.13.2.6 VTS operator training – the NCA’s training regime

The AIBN has received documentation from the NCA, including about training and
refresher courses for VTS operators. Reference is made to the NCA’s certification course
for VTS operators.

The following are among the goals for the course, which also include communication
training:

The candidate shall:

 Be capable of clear, concise, correct, timely and meaningful
communication through repeating, dividing up and rewording messages.
 Be capable of speaking clearly and accurately on a VHF radio.
 Be capable of using a VHF radio for emergency communication, among
other things.
 Be capable of using message markers, information-informasjon, question-
spørsmål, answer-svar, warning-advarsel, advice-råd, request- x and
instruction-instruksjon. (English and Norwegian)
 Be capable of issuing result-oriented messages
 Know how to issue information to maritime traffic about the various rules
that apply within a VTS area.

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Every five years, personnel from the different VTS centres attend courses in Copenhagen
together with the pilots. The purpose is to gain a better understanding of each other’s
roles.

1.13.2.7 Follow-up of the VTS centres

The procedure for operation of the service (Drift av tjenesten), issued by the NCA’s
Department for Maritime Safety, sets the premises for internal reviews by each individual
VTS centre. Internal reviews shall be carried out annually by each individual VTS centre,
relating to, among other things, training, competence, procedures and practice. The
purpose of the internal review is to identify specific improvement measures through
dialogue, observation and reviewing documents and technical systems. The reviews are
organised by the quality coordinator at the centre for pilotage and vessel traffic service
(SLVTS).

An internal review of Fedje VTS was carried out on 18 and 19 June 2018. According to
the report from the review, there was little that warranted attention concerning the
observations that were made in the tower during the review. The following comments
were made, however, concerning the review of the audio recording that were obtained
prior to the internal review:

Some comments on the manner of communication. Little use of message markers.

Some unnecessary use of politeness phrases. Most things are done according to
the book at times, but occasionally there is too much chatter etc. One important
question is how to get everybody to work as uniformly as possible and in
accordance with applicable procedures and instructions.

Among other things, the report raised the question of how it can be ensured that VTS
operators act in accordance with the instructions for brief and concise communication.
One measure was that the NCA should organise an e-learning programme to be
completed by all VTS operators.

1.13.3 Fedje VTS

1.13.3.1 Responsibility and guidelines

Fedje VTS belongs to NCA Western Norway (see Figure 38). Fedje VTS is responsible
for the traffic area between Marstein in the south, Sognesjøen in the north and Bergen in
the east (see Figure 39). All vessels of 24 m or more must have permission from Fedje
VTS before entering the service area; see the Maritime Traffic Regulations.

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Figure 39: The Fedje VTS area and overview of working channels to be used for VHF radio
communication. Map: The NCA

Fedje VTS has a total of 14 VTS operators working eight-hour shifts throughout the day
and night. In addition, there is one VTS manager and three employees who service
technical equipment and buildings.

Traffic is at all times monitored from two workstations in the control room at Fedje VTS
by two VTS operators covering different parts of the VTS area. In the northern part, the
main focus is on tankers crossing the fairway, and in the southern part, special attention is
paid to the potential for conflicting traffic in the narrow waters at Vatlestraumen and
Kobbeleia, to avoid unfavourable head-on situations. In addition, Fedje VTS has special
focus on vessels requesting pilotage in the challenging waters around Marstein.

The internal instructions for traffic organisation for Fedje VTS (see Appendix C) points
out that the Grimstadfjord (Haakonsvern)/Raunefjord/Vatlestraumen areas are sometimes
heavily trafficked by military vessels, which often sail without AIS or VHF radio

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notification. The VTS operator must pay special attention to this. Fedje VTS has no
further instructions or procedures for handling naval vessels.

Most of the maritime traffic being monitored and organised from Fedje VTS consists of
ships in transit along the coast, ships calling on the Sture and Mongstad oil terminals and
at the CCB Ågotnes and CCB Mongstad supply bases, in addition to inbound and
outbound traffic from Bergen. Ships bound for and leaving Sløvåg are also monitored.
Approximately 400 large crude oil tankers, 1,100 smaller product tankers and 270 gas
tankers pass through the VTS area annually.

According to the NCA’s solution for statistical monitoring of vessel traffic, Havbase.no,
statistics are kept of the number of vessels passing defined lines along the coast. One
such passing line is defined a short distance to the north of the Sture Terminal. According
to the database, the number of vessel passages across this line totalled 12,579 in 2018.
The records are based on active AIS transmission by the vessels. In practice, this means
that the figures do not reflect all vessel traffic (many pleasure craft and other vessels of
less than 24 m are, for example, not included)

1.13.3.2 Equipment and system for monitoring maritime traffic

There is full AIS coverage throughout the Fedje VTS area, but some areas lack radar
coverage (blind zones). Fedje VTS also has two cameras – one covering Vatlestraumen
and the other covering the area near the mouth of the Fensfjord and the approach to
Mongstad. It does not have any cameras covering the area near the Sture Terminal where
the accident occurred.

The Norwegian Coastal Administration’s VTS centres use the system C-Scope as a
support tool for monitoring and handling maritime traffic. C-Scope uses AIS, radar and
other sensors (for example cameras and VHF direction finders) as sources of information
about maritime traffic.

C-Scope is a system that integrates and processes the data transmitted from sources and
sensors. The image that is generated and displayed to the VTS operators is filtered and
intended to provide an overview of the traffic situation, thus alleviating their tasks and
putting less pressure on the operators.

The VTS centre’s operational support system (OSS) gives VTS operators access to vessel
and voyage information registered in SafeSeaNet37, and the system includes tools that can
be used to assist the operators in emergency situations.

AIS and radar are the most important information sensors in C-Scope. Plotting/tracking
can be automatic, manual or a combination of the two. A plotted target is normally not
generated from a single source of information, but is a product of information from the
available sensors. Information about a single vessel is often obtained from several
sensors, with slightly varying time stamps. Two course/speed lines are only displayed
very occasionally (when using both AIS and radar inputs) for one and the same vessel.
The information will usually be unambiguous, regardless of whether the target is being
tracked by one or more sensors.

37
SafeSeaNet Norway is an online notification system used by the shipping companies to submit mandatory
information about arrivals and departures to Norwegian authorities and ports.

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For various reasons, AIS transponders may occasionally give incorrect indications of
position and speed. Radar information is generally more reliable than AIS information
with respect to position and course/speed. The information that users enter in AIS may
also be inadequate, and misinformation can be entered intentionally or unintentionally.
As a result of the C-Scope function for quality assessment and integration of information
from the various input sensors, the reliability of the various plots is considered to be high.

Vessels that can only be observed on the radar display can be identified through direct
communication between the vessel and the VTS. The operator can then obtain more
information about the vessel on the OSS.

Since August of 2015, the monitoring system at Fedje VTS has been able to receive and
display encrypted Warship AIS. The system was tested in August of 2015 and allegedly
functioned properly. A test in September of 2019 did confirm that Fedje VTS could
receive and display W-AIS on their monitors. The monitoring system does not
differentiate between standard AIS (mode 1) and encrypted AIS (mode 3); it displays
encrypted and unencrypted AIS with identical symbols.

1.13.3.3 The VTS operator’s workstation

The traffic operators’ workstation is set up with three main screens and three overview
screens up above (see Figure 40). The screens are a part of C-Scope. The terminals are
called C-Scope Operator Client (C-SOC). The settings on C-SOC are mainly controlled
by the VTS operator, and most VTS operators have a start screen to which they log on
when they go on duty. There are only slight variations between the start screens used by
the different VTS operators.

The main screens normally also cover some of the area bordering on the VTS area, so any
vessel notifying of its entry just before crossing the border can also be observed by the
operator. The operator is able to move freely between the screen and within the area in C-
SOC. The operator’s screen layout was centered as normal to cover around 1-1.5 nm
outside the VTS area.When ‘HNoMS Helge Ingstad’ notified of entering the area at
02:38, the VTS operator (Area North) did not see the vessel’s radar echo on the main
work screens because it was outside this area. The VTS operator saw an echo on the
overview screen, which was assumed to be the naval vessel.

The AIBN understands from interviews with personnel at Fedje VTS that it can be
difficult for operators to keep the total picture in view while focusing on a particular
location. The VTS centres have routines to monitor the VTS areas to detect vessels
sailing into the areas or leaving quay or anchorage.

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Figure 40: Workstation for the VTS operator monitoring the northern part of the Fedje VTS area.
The three ‘main screens’ are marked with a red circle. The overview screen is placed above the
main screens. Photo: AIBN

1.13.4 The pilotage service

1.13.4.1 General information

The NCA is responsible for Norway’s national pilotage service. By pilotage is meant
guidance relating to vessels’ navigation and manoeuvring. The pilotage service helps
safeguard traffic at sea and protect the environment by providing vessel crews with
necessary knowledge of the fairways. The service comprises around 285 pilots with local
knowledge who have special training in navigating the Norwegian coastal area for which
they hold a certificate.

A pilot is a person employed by the pilotage service who holds a pilot licence issued in
accordance with the Act of 15 August No 61 relating to pilotage (the Pilotage Act). The
Act does not entail any change of rules relating to the master’s responsibility. The pilot is
responsible for the pilotage. The master may surrender control of the vessel’s propulsion,
navigation and manoeuvring to the pilot.

1.13.4.2 Pilotage instructions

The purpose of the NCA’s pilotage instructions (LOS 09.04 – Utførelse av losingen) is to
ensure that pilotage assignments are carried out in a safe and efficient manner. The
following is stated in section 3.1 of the instructions on ‘Allocation, preparations for and
execution of the assignment’:

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- The pilot shall plan the pilotage assignment, in collaboration with the master
and the bridge crew.
- Regardless of the manner in which the master or the officer in charge
announces that the pilot shall be take over the control or being replaced, the
pilot shall indicate this by saying, respectively: ‘Pilot has the con’ or ‘Captain
has the con’.
- The pilotage shall be communicated accurately so that misunderstandings do
not arise.
- During pilotage, the pilot shall continuously monitor and check the vessel’s
position, heading and speed.
- A pilot is considered to be part of a ship's bridge team and shall help the team
to cooperate and communicate optimally (good BRM).
- If, during a pilotage assignment, the pilot finds that the prerequisites for good
BRM are not present, the pilot shall make the best of the situation in order to
carry out the assignment safely. In such instances, the situation shall be
reported to the head of the pilot services along with the nonconformity, so that
the shipping company or shipping agent can be notified.
- In situations entailing a risk of personal injury, environmental damage or
major material damage, the pilot may act on the principle of necessity if such
harm cannot be otherwise prevented. The damage risk in the emergency
action must be far less than the damage risk in the event you want to avert.
- The pilot shall communicate with the VTS operator in the language that has
been clarified with the ship’s captain / bridge crew for bridge communication.
- Communication with VTS operator about passing or conflicts with vessels
communicating in English shall take place in English. This is to ensure that
the vessels involved understand all communication so that misunderstandings
do not arise.
- If the vessel is within an area covered by a VTS centre, the pilot may contact
the VTS, which is authorised to issue orders to the ship as necessary.
1.13.4.3 Compulsory pilotage and pilot exemption certificates

Compulsory pilotage is regulated by the Regulations of 17 December 2014 No 1808 on

compulsory pilotage and use of pilot exemption certificates (the Compulsory Pilotage
Regulations). The Regulations stipulate which vessels are subject to compulsory pilotage
and the waters where the requirement applies. The general rule is that all vessels with a
length of 70 metres or more are subject to compulsory pilotage when operating in waters
within the baseline.

Pursuant to Sections 3 and 4 of the Compulsory Pilotage Regulations, Sola TS was

subject to compulsory pilotage when heading out from the Sture Terminal and sailing
through Fedjeosen. The Regulations do not apply to military vessels or other vessels
under military command.

The Compulsory Pilotage Regulations permit sailing without a pilot on certain conditions
stipulated in the provisions on pilot exemption certificates (PECs).

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The following is retrieved from the NCA’s website [translated from Norwegian]
concerning pilot exemption certificates:

Vessels of a certain size are subject to compulsory pilotage when operating inside
Norway’s baseline (applies to the mainland and Svalbard). A navigator with a
valid exemption certificate can often meet the requirement without using a pilot.
Pilot exemption certificates are based on control by the authorities of the
navigator’s experience, competence and skills on a specific vessel in specific
waters.

1.13.5 Traffic from the Sture Terminal

From the AIBN’s interviews with personnel at Fedje VTS, it appears that the VTS
operators perceived Sola TS as departing in the normal manner from the Sture Terminal
and in line with how this is often done. This is largely confirmed by data retrieved from
the NCA’s Havbase.no (see Figure 41). Tankers and LPG tankers arrive approximately
every other day to the Sture Terminal.

There was no specific discussion at Fedje VTS on this point. The alternative would be to
cross the fjord a little further and make a wider turn, but this is not seen as an option in
the case of big tankers. It is also evident from the interviews that the part of the voyage
from departure until the tanker passed Fedjeosen was handled by the on-board pilot, and
that the VTS did not find it natural to oversee this.

It was furthermore evident from the interviews that the times at which the different pilots
notify Fedje VTS of departure varies. When the pilot notifies of a vessel taking in the
mooring lines, this is an indication to the VTS that the vessel will leave the quay within
the next hour. There are also differences as to where the pilot is in the departure
procedure when the VTS is called for the second time. Some pilots call Fedje VTS when
the mooring lines have been retrieved, while others call when they have left the terminal
and are about to turn.

The VTS operators have told the AIBN that, after the introduction of AIS and electronic
sea charts, vessels generally operate differently from what they did before. They now take
the shortest route when heading out through the fjord, as opposed to what was previously
the case, when the vessels steered by light sectors and to starboard of the middle of the
fairway.

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Figure 41: The chart on the left shows the routes taken by tankers of between 50,000 and
100,000 GT in November 2018. The chart on the right shows all traffic of tankers and mixed
cargo vessels of all sizes during the same period. The tankers operate along the western side of
the Hjeltefjord so as to minimise the length of the approach/departure passage from the Sture
Terminal. Other traffic is spread across the width of the fjord, depending on vessel destinations.
Map: The NCA, havbase.no

1.13.6 Communication between the VTS centre and vessels

Resolution A.918(22) IMO Standard Marine Communication Phrases (SMCP), states in

A.857(20) that the phraseology used in the communication between the VTS centre and
the vessel should clarify the message content and prevent misunderstandings. In any VTS
message directed to a vessel, it should be made clear whether the message contains (1)
Information, (2) Advice, (3) Warning or 4) Instruction.

How the communication between the VTS centre and vessels should be conducted is
regulated by a procedure issued by the NCA’s Department for Maritime Safety. The
following is stated in section 3.1 ‘Communication’:

Within the VTS area, the VTS operator will, as a rule, communicate with vessels
by VHF radio, using terminology as described in ‘IMO STANDARD MARINE
COMMUNICATION PHRASES’. The VTS operator will communicate with the
Armed Forces’ vessels in public service by mobile phone when this is necessary
for the vessel to complete its assignment. The VTS operator will seek to keep
communication by VHF radio brief and concise.

The procedure also includes a chapter regulating the VTS operators’ use of message
markers.

Concerning the language of communication, the procedures states:

The VTS operator communicates with vessels in the language the vessel uses for
communication with the VTS. Communication with any vessel about overtaking or
conflicts with vessels that communicate in English takes place in English. This is
intended to ensure that the vessels involved understand all the communication and

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thus prevent misunderstandings. If conflicts arise between vessels that clearly

communicate in different languages, the VTS operator will ensure that any
necessary information, advice, warning or instruction is communicated in both
Norwegian and English.

The AIBN has been informed that there have been discussions in the NCA concerning
what language the VTS centres should use. At present, the VTS operators speak
Norwegian to navigators who speak a Scandinavian language and English to non-
Scandinavian speakers. The VTS operators have been reluctant to use English for all
communication, because the crew on smaller vessels sometimes have a limited grasp of
the English language. They have held that, by communicating in English only, they will
lose more in relation to navigators who speak a Scandinavian language than they will
gain in relation to those who do not. When dealing with a situation that involves both
those who speak a Scandinavian language and those who do not, the VTS operators
follow the practice of issuing information in both languages.

1.14 Medical and personal considerations

1.14.1 Generally

The AIBN has not found that any of the personnel involved were affected by alcohol
and/or other drugs/medications at the time of the accident. Nor has the investigation
revealed any personal conditions or distractions that are relevant to the accident, other
than aspects related to visual function and fatigue (see sections 1.14.2 and 1.14.3).

1.14.2 Examination of visual quality for the bridge crew on HNoMS Helge Ingstad

1.14.2.1 Introduction

The Department of Occupational Medicine (Helse Bergen health trust), has, on

assignment for the AIB, performed eye tests on the seven crew members who made up
the bridge team at the time of the accident. The AIBN has received a specialist report
with assessment of the crew’s eyesight. The report describes the methods used to test the
crew’s vision and the regulations under which vision is assessed (see extract in Appendix
D). The Department of Occupational Medicine has been presented with photos and video
recordings from the observation voyage that took place on the night leading up to 2 April
2019.

1.14.2.2 Findings in the vision tests

The examination and assessment of vision and the medical information the AIBN
received from the Navy, gave the following findings:

- One of the bridge team members should, according to the specialist report, under the
regulation on military health service and medical assessments (Bestemmelse for
militær helsetjeneste og legebedømmelse – FSAN P6) and the instructions concerning
medical requirements for the Navy (Instruks om helsekrav for Sjøforsvaret), be
assessed as fit for service in the Armed Forces but not for service in the field or at
sea.

- One bridge team member was, according to the specialist report, unfit for service in
the Armed Forces under the regulations, including for sea duty and bridge duty, also

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unfit for service on Norwegian vessels for work requiring a certificate. The
assessment in the specialist report does not correspond to the medical information
from the Navy. The military doctor considered the person in question as fit for sea
duty, but unfit for bridge duty. According to the Department of Occupational
Medicine, the military doctor gave the wrong diagnosis of the condition. There are
deviating findings in the examination, and the regulations have not been complied.

- Two of the bridge team members had, according to the specialist report, reduced to
low contrast sensitivity38, especially in twilight conditions and twilight with glare.
According to the specialist report both persons were fit for service in the Armed
Forces under the regulations, including for sea duty and bridge duty. The current
regulations do not contain mechanisms for identifying personnel with low contrast
sensitivity in the absence of predisposing factors. The Navy was not aware of the
person having reduced contrast sensitivity.

- In the case of one bridge team member, the requisite report, specialist assessment and
examination by a military doctor after corrective eye surgery, were not available as
required by the regulations.

- Several of the reduced visual functions were unknown to both the Navy and the
individuals themselves.

- The remaining three members of the bridge team had normal visual.

Furthermore, the following is cited from the specialist report by the Department of
Occupational Medicine:

Several members of the bridge team had reduced vision, as a result of this two did
not fulfil the formal requirements for bridge watchkeeping in the Navy. In the
actual situation it was local light pollution involving glaring lights and negative
contrasts39 during parts of the sequence of events.
Local light pollution in combination with reduced vision could mean that ordinary
visual stimuli such as navigation lights and other lights were difficult to detect. It
is, however, considered that bridge crew’s total visual competence was sufficient
for safe naval navigation in the current situation. When considered the effect of
reduced vision for individuals, the function of each member and how work was
organised on the bridge is essential. It is therefore not possible based on the
results from the tests by the Department of Occupational Medicine alone to say
anything specific about the degree to which reduced qualities of vision for the
persons can be considered a contributing factor to the incident.

38
Contrast vision is the eye's ability to perceive different light intensity. A person with reduced contrast vision sees less
than normal when the contrasts in the surroundings are reduced. There is no widely accepted first choice of standard for
measurement of contrast sensitivity, and the various methods are only to a limited extent validated in relation to each
other (see Appendix D). There is no minimum threshold value for contrast sensitivity in relation to approval as bridge
crew.
39
Navigation lights and other lights had lower light intensity than the deck lights, thus the threshold for object detection
will increase.

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1.14.3 Fatigue, sleep deprivation and circadian rhythm

Appendix B describes theory relating to fatigue, sleep deprivation and circadian rhythm.

1.15 Special investigations

1.15.1 Analysis of data from the navigation system

1.15.1.1 Introduction

The Navy’s internal investigation team has analysed the data from the navigation system
and IPMS for HNoMS Helge Ingstad as of 8 November 2018. The analysis considered
objective findings and related professional assessments.

1.15.1.2 The headings of HNoMS Helge Ingstad

Based on information from the navigation system, the graph in Figure 42 shows the
headings of HNoMS Helge Ingstad in the period from 03:58:06 to 04:01:36.

Figure 42: The headings of HNoMS Helge Ingstad in the period from 03:58:06 to 04:01:36.
Illustration: AIBN

1.15.1.3 Summary of navigation data

Main analysis findings relating to the sequence of events prior to the collision:

- There is no evidence of there having been any fault or defect in the navigation
system or connected sensors with the exception of occasional faults in GPS 2 that
had consequences for active AIS transmission [after the collision]
- The navigation system settings were in accordance with the standard for Fridtjof
Nansen-class frigates. It is therefore highly probable that Sola TS and Tenax were
visible as AIS contacts on all MFDs on the bridge.

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- Sola TS and Tenax were not tracked by radar and/or AIS, and did not therefore
generate any alarm for ‘Collision Danger’ or ‘Proximity Violation’
- It is highly probable that Sola TS could be seen on the radar, given that Dr. No,
Seigrunn, Vestbris and Silver Firda were tracked and generated alarms.
- HNoMS Helge Ingstad did not reduce her speed before the collision
- Data from IPMS show that, at 04:01:17, the starboard and port rudders on the
steering console were both approximately 30 degrees to port of zero degrees. The
actual rudder angle was 10° on both rudders. It is therefore highly probable that
full rudder to port40 was ordered immediately prior to the collision.

1.15.2 Reconstruction of information shown on the navigation console displays on HNoMS

Helge Ingstad

1.15.2.1 Introduction

The Navy’s internal investigation team has made a reconstruction of what was shown on
the displays on the different navigation consoles (MFD 1–3) on HNoMS Helge Ingstad
on 8 November 2018. The reconstruction is based on the log files from HNoMS Helge
Ingstad showing a reference position every time the chart section on the ECDIS (MFD 3)
is moved away from the vessel (Browse) or the centre of the radar image is moved on
MFD 1 and MFD 2 (offset/off-centred).

The log files from HNoMS Helge Ingstad do not give information about radar tuning, i.e.
which settings were chosen in order to minimize noise, gain or any other functions in use.
Furthermore, it is not possible to recreate the magnitude of the radar echo from Sola TS
or whether there were trails on the echoes.

The reconstructed displays do not provide exact replicas of what was shown on board
HNoMS Helge Ingstad. According to the Navy’s internal investigation team, they can be
deemed to have an accuracy of 0.1–0.2 nm (185–370 m) depending on the chart/radar
range scale.

1.15.2.2 Settings on MFD 1 and MFD 2 during the voyage

Table 4 and Table 5 show the settings on the OOW’s radar display (MFD 1) and the
OOWA’s radar display (MFD 2), respectively. Note that the orientation and presentation
mode on both radars were constantly in North UP/True Motion (NUP/TM)41.

40
This does not tally with the information the AIBN received through interviews with the bridge crew.
41
From the radar manual: North Up (NUP): The orientation of the screen becomes northwards. The direction of the
heading line changes during manoeuvres. TM (True Motion): In true motion, the own-ship symbol moves across the
Radar picture while the picture remains fixed.

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Table 4: Settings on the OOW’s radar display (MFD 1 = X-band radar)

From (time): Radar range Chart scale:
scale:
02:52:26. 6 nm 1:77293
03:03:04. 3 nm 1:38646
03:21:48. 6 nm 1:77293
03:21:51. 3 nm 1:38646
03:36:49. 6 nm 1:77293
03:37:01. 3 nm 1:38646
03:46:58. 6 nm 1:77293
03:47:01. 12 nm 1:154586
03:47:26. 6 nm 1:77293
03:47:59. 3 nm 1:38646
03:50:16. 6 nm 1:77293
03:50:28. 3 nm 1:38646
03:55:04. 6 nm 1:77293
03:55:16. 3 nm 1:38646
03:59:00. 1.5 nm 1:19323

Table 5: Settings on the OOWA’s radar display (MFD 2, S-band radar)

From (time): Radar range Chart scale:
scale:
02:50:50. 6 nm 1:77293
03:57:44. 3 nm 1:38646

1.15.2.3 Optical bearings during the voyage

The MFD 3 display (ECDIS/chart display) was in Browse mode up until the time of the
collision. On this display, optical bearings are used to check the vessel’s position. Data
from the bridge console indicated that optical bearings were taken several times between
03:30 and 04:00 on 8 November 2018:

At 03:38:40 Position Line, Onglesundet light in bearing 125.0°

At 03:42:17 Position Line, Onglesundet light in bearing 108.5°
At 03:44:19 Position Line, Onglesundet light in bearing 094.0°
At 03:44:59 Position Line, Flesi light in bearing 146.5°
At 03:46:10 Position Line, Flesi light in bearing 117.7°
At 03:46:58 Position Line, Onglesundet light in bearing 070.6°
At 03:53:13 Position Line, Flesi light in bearing 084.4°
At 03:55:42 Position Line, Ådneset light in bearing 182.0°

When optical bearings are to be used to find the vessel’s position, a work sequence is
started during which the OOW and the OOWA work together. On this particular voyage,
the OOWT and the OOWAT worked on this together. The sequence starts with the
OOW/OOWT deciding which objects to take bearings of and communicating this to the
OOWA and the OOWAT. The OOWA/OOWAT finds these objects in ECDIS, opens the
‘Position Line’ dialogue box on the display and scales the chart as necessary. If the
OOWA/OOWAT has problems finding the objects on the chart, the OOW/OOWT can
explain or point out where the object is on the chart.

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The OOW/OOWT takes bearings of the objects with the optical pelorus, and announces
the bearings in three digits, which are then entered in the ‘Position Line’ dialogue box by
the OOWA/OOWAT. This part of the sequence is repeated for each object.

The bearing lines of each object are presented on the ECDIS display, and the vessel’s
position is in the intersection between the lines. The OOWA/OOWAT then informs the
OOW/OOWT of whether the vessel’s position is to starboard or port of the planned route.
The OOW/OOWT assesses the vessel’s position and whether it is necessary to correct the
course to revert to the planned route.

If the OOW/OOWT is uncertain of the accuracy of the positioning, or whether it was

done correctly, the work sequence is restarted. That is why data from MFD 3 show that
bearings were taken of the same object several times within a short time interval.

During the positioning process, the OOW/OOWT will focus on what is going on outside
the vessel and on the use of the pelorus, while the OOWA/OOWAT will focus on the
ECDIS display.

1.15.2.4 Summary of reconstruction

The following is reproduced from the Navy’s summary of the findings made during the
reconstruction:

The reconstructed displays indicated that the scaling and offsetting of X-band and
S-band radars were in accordance with normal practice. The investigation team
has no information to indicate that there were any technical problems with the
radar or AIS. It is therefore natural to assume that that Sola TS was visible on the
radars.
It is normal practice to choose presentation of AIS targets on both the radar and
ECDIS displays. Since data from the navigation system do not indicate whether
this was the case, AIS targets were not plotted on the reconstructed displays.42
It is also normal for ECDIS to be set to BROWSE mode when looking for objects
to take optical bearings of, checking sounding depths etc. Note that route
monitoring continues in the background on MFD 3 even if the chart shown on the
display is off centre in relation to the vessel’s position. The route was also
monitored on both radars.

1.15.3 Observation voyage

1.15.3.1 Introduction

In order to get a better picture of the situation as it might have been perceived by the
bridge team on HNoMS Helge Ingstad, a voyage was conducted on 2 April 2019 with the
frigate HNoMS Roald Amundsen at the same time as Sola TS left the Sture Terminal,
under conditions that were as similar as possible to the night leading up to 8 November
2018. The voyage covered the period from when Sola TS started manoeuvring until
shortly before the collision. A set of positions that the two vessels were to occupy at
42
It has not been possible to reconstruct the AIS targets plotted on MFD 1–3 during the voyage, because this
information is not stored in the navigation system, but, in accordance with the functions (default settings) described in
the supplier’s manuals, all vessels with AIS transmission that are within range will be represented by symbols on the
radar and ECDIS displays.

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given times, had been agreed in advance. The purpose was to ensure that course/speed,
bearings and distances between the two vessels would resemble the sequence of events on
8 November as much as possible.

1.15.3.2 The voyage

The wind was slightly stronger and more than on the night of the accident. It was also a
cloudy day, but the light and visibility conditions were deemed to be relatively similar to
those on the night of the accident (see Appendix A).

During the southbound voyage from Fedje towards the Sture Terminal, the bearing of
Sola TS relative to the heading of HNoMS Roald Amundsen was gradually reduced from
161.4° to 159.0°. On the night of the accident, the bearing of Sola TS relative to the
heading of HNoMS Helge Ingstad was gradually reduced from 162.7° to 160.8°.

Because of the prevailing wind conditions on the observation voyage during the night
leading up to 2 April 2019, Sola TS set a more northerly course sooner than it did on the
night of the accident.

Video recordings were also made from the bridge of HNoMS Roald Amundsen and Sola
TS to document what things might have looked like on the night of the accident. The
observers on the bridge of HNoMS Roald Amundsen had two sets of binoculars
available, identical to those that were available on HNoMS Helge Ingstad during the
night of the accident. An observer from the AIBN was also present on board Sola TS
during the voyage.

Appendix F shows images from the observation voyage based on video recordings made
from the bridge on HNoMS Helge Ingstad by the police.

1.15.3.3 Observations made during the voyage

When Sola TS lay alongside with all deck lights switched on (including those that
pointed aft), the vessel’s lights were distinct from the terminal lights. The vessel’s deck
lights had a more yellow glow than the terminal’s lights. The terminal’s lights were
perceived as having less luminous intensity and a whiter hue than the vessel’s deck lights.
Without knowing what you were looking for, it was difficult to ascertain that the lights
came from a vessel.

Without the use of binoculars, the vessel became one with the terminal’s lights when the
crew on Sola TS switched on the aft-pointing deck lights. With the aid of the Navy’s
binoculars, it was nonetheless possible to discern a vessel alongside when conducting an
active search among the lights.

When Sola TS started to turn her bow seawards from the quay, this was done so slowly
that it was difficult to see any movement from the frigate’s position. The lights exhibited
by the vessel were also not visible to the naked eye. Other lights on the vessel appeared to
be an extension of the terminal’s lights and of similar hue (light/yellow/white). It was not
possible to spot the forward-pointing yellow deck lights to start with. Only with the aid of
binoculars and being conscious of what one was looking for, was it possible to perceive
this as a vessel. During one period, the lights from the escorting boat could be observed
between the stern of Sola TS and the quay at the Sture Terminal. When the vessel had

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moved away from the quay, it was no longer observed as an extension of the quay and the
background lighting.

As Sola TS turned her bow northwards and in the direction of the observers on the
frigate’s bridge, the yellow deck lights became visible. As Sola TS continued to turn and
establish a northerly course (opposite course to HNoMS Roald Amundsen), the forward-
pointing deck lights gave off more light and finally became very sharp and clearly
observable from HNoMS Roald Amundsen.

For observers on the frigate bridge it was almost tempting to ‘hide the deck lights from
Sola TS’ behind one of the window bars so as not to be dazzled. The lights from the
tanker gave the impression of something square-shaped. As the vessels drew closer to
each other, the lights appeared to increase in intensity, but it was difficult to estimate the
distance or ascertain what was behind the lights.

Estimating the distance was challenging because of the lack of reference points within the
field of vision. When HNoMS Roald Amundsen broke the voyage approximately1 nm
from Sola TS and the vessels passed each other port to port, the contours of the tanker
started to appear when the observers were no longer dazzled by the floodlights. If
observed from the side or from any angle abaft of midship, Sola TS was quite visible.

During the observation voyage, the side lights of the tanker could be distinguished
through the binoculars; especially if you knew what you were looking for. The observers
had slightly varying opinions on this point. Some were able to see the three all-round red
lights and the flashing red light on Sola TS through the binoculars.

When the vessels were getting closer to each other and Sola TS signalled with the Aldis
lamp, the flashes could only just be discerned between the yellow deck lights without the
aid of binoculars, but this required looking straight into the strong yellow lights. Through
the binoculars, the Aldis lamp could be seen more easily.

As Sola TS moved further away from the Sture Terminal and the ‘effect’ of the forward-
pointing deck lights increased, the vessel stood more and more out as a separate object
that was unrelated to the Sture Terminal. The distance between Sola TS (with strong
yellow deck lights) and the Sture Terminal became considerable and could be more easily
observed as the two vessels came closer to each other. The strong yellow deck lights from
Sola TS became clear and could easily be seen from all positions on the bridge of
HNoMS Roald Amundsen.

1.15.4 Simulation of last chance for anti-collision manoeuvre

The AIBN has been provided with information about the manoeuvring characteristics of
HNoMS Helge Ingstad and Sola TS in relation to the vessels’ engine configuration and
speed during the time leading up to the collision.

HNoMS Helge Ingstad was significantly more manoeuvrable than Sola TS, and the AIBN
therefore requested an opinion/simulation from Safetec Nordic AS of the potential effect
on the sequence of events of a ‘crash-stop’ and full-rudder-to-starboard manoeuvre,
respectively, on the part of HNoMS Helge Ingstad. The purpose of the assessment was to
identify the ‘point of no return’, that is the last chance to make a manoeuvre to avoid the
collision.

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The simulation has shown that a crash-stop manoeuvre on the part of HNoMS Helge
Ingstad must have been carried out approximately 68 seconds before the collision when
there was a distance of approximately 750 m between the vessels.

Had a manoeuvre as shown in Figure 43 with full-rudder-to-starboard on the part of

HNoMS Helge Ingstad, been carried out when 38 seconds remained before the collision
and the distance between the vessels was approximately 375 m, the collision could have
been avoided, but the CPA would have been 0–25 m.

Figure 43: Had HNoMS Helge Ingstad made a manoeuvre to starboard 38 seconds before the
collision, the collision would probably have been avoided. The vessels would then have passed
each other port to port with a CPA of approximately 0 - 25 m. Illustration: Safetec/AIBN

1.15.5 Use of external consultants

In addition to the simulation in 1.15.4, the AIBN commissioned Safetec Nordic AS,
among others, to review and evaluate the functionality and use of the navigation
equipment on HNoMS Helge Ingstad.

The AIBN also commissioned the consultants Hærem, Andersen and Kost to map
theoretical perspectives so as to be able to understand what cognitive and organisational
challenges a navigation team is faced with. Their report (see Appendix G) considers
different forms of common perceptual and cognitive limitations, how these can interact in
a bridge team, and how this can be identified and dealt with.

1.15.6 DNV GL – Mapping of the safety culture in the Fleet and in the Navy’s executive staff

As part of the Armed Forces’ internal investigation of the accident involving HNoMS
Helge Ingstad, DNV GL was commissioned by the Norwegian Defence Logistics
Organisation (NDLO) to conduct a survey of the safety culture in the Fleet and among the
Navy’s executive staff. The survey was initiated to be able to understand and describe the
safety culture of the Fleet in general and among the Navy’s executive staff, regardless of
the specific circumstances under which the accident occurred. DNV GL’s survey of the

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safety culture consisted of questionnaires (a total of approx. 500 respondents) and

interviews (a total of 160 interviews).

Based on the questionnaire survey, DNV GL identified nine fundamental assumptions

that express the prevailing culture in the Fleet/Navy. These assumptions can reflect
strengths in the culture, but also challenges. In total, DNV GL identified 17 challenges
relating to competence and manning, cooperation and involvement, alertness, conflicting
goals, incentives, compliance, robustness and organisation learning. The findings are
described in Appendix E.

1.16 Other information

1.16.1 The BRM concept

Bridge Resource Management (BRM) is a maritime adaptation of the aviation concept

Crew Resource Management (CRM). BRM is used to describe important principles for
optimum utilisation of available resources (human and technological) to ensure a safe
voyage. Important principles include teamwork, communication, leadership, decision-
making and resource allocation, as well as how tasks are performed and affected by
factors like stress, attitudes and understanding of risk. The BRM principles apply to the
preparation and planning of the voyage, the voyage itself and the evaluation of the
voyage on arriving at the destination (Wahl & Kongsvik, 2018, Swift, 2004 and Adams,
2006).

The main objective of a well-functioning bridge team is to ensure that individual team
members’ undesirable actions or inaction are registered by the team, so that the team can
take necessary action to maintain control of the vessel. This reduces the risk of exposing
the vessel and crew to danger. IMO has made BRM training a formal requirement for
navigation officers on the bridge and in the engine room (IMO, 2011).

1.16.2 COLREGs

The Regulations of 12 January 1975 No 5 for preventing collisions at sea (COLREGs),

are international rules that apply to all vessels. In addition to the requirements mentioned
in section 1.9.5 relating to the use of lights, the COLREGs also contain provisions on
keeping a lookout, safe speed, collision danger and collision avoidance manoeuvres.

1.16.3 Previous accidents involving pilots

1.16.3.1 Grounding of ‘Federal Kivalina’ at Årsundøya on 6 October 2008

The AIBN’s investigation into the grounding of ‘Federal Kivalina’ (Report Marine
2010/01) revealed that the ship’s bridge crew were not sufficiently prepared for the five-
hour voyage from the pilot boarding place to the quay, and that the bridge team and pilot
did not function together as intended. The ship’s bridge crew and pilot had not deemed it
necessary to work as a bridge team, and the pilotage service had also not stipulated
sufficient requirements for the pilot to act as part of the bridge team. In practice, there
was just one person, the pilot, who performed active navigation, and no one checked the
voyage after having arrived at the pilot boarding place. The bridge crew paid less
attention to the navigation of the ship after the pilot’s arrival.

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1.16.3.2 Grounding of ‘Crete Cement’ in the Oslofjord on 19 November 2008

In the AIBN’s investigation of the grounding of ‘Crete Cement’ (Report Marine

2010/04), it was found that barriers that should have been in place when the pilot did not
change course in time, were weak or absent. The navigation officer on watch was
required to deal with other tasks that distracted him from navigational tasks, and no
additional bridge resources were mobilised for the passage through the narrow fairway.
During the voyage, communication between the pilot and the navigation officer on watch
was limited to practical issues and the details of the passage were not discussed.

1.17 Implemented measures

1.17.1 The Navy

The Navy has conducted its own investigation of the accident. The report was not
completed at the time this preliminary report was published. The AIBN has received
information about measures taken by the Navy after the accident (see Appendix H).

In addition to the measures implemented as described in Appendix H, the AIBN has

received information about the following:

- The Navy has developed a BRM training programme adapted to frigate bridge teams.
Three frigate crews have completed the programme in connection with sea training.

- The Navy has established a dedicated CRM instructor course in cooperation with the
US Navy. The course is intended for seagoing personnel on the Navy’s vessels for the
purpose of raising CRM competence on board. This will allow the vessels to conduct
dedicated CRM training of its teams. The first CRM instructor course was held in
March 2019.

- The Navy is in the process of establishing a working group tasked with evaluating,
and if applicable, revising the instructions concerning medical requirements for the
Navy (Instruks om helsekrav i Sjøforsvaret), including eyesight requirements by
summer 2020.

- The organisation as a whole is reviewing and improving the system to ensure that
personnel on the Navy’s vessels are fit for service in their respective functions.

1.17.2 Tsakos Columbia Shipmanagement S.A.

The AIBN has received information on the measures the company has taken following its
initial investigation of the accident. As implemented measures, the company points out
the following:

- Notified all vessels in our fleet operating in the Sture region as follows:

o To exercise extra caution when ordered to the Sture due to potential fast
moving military craft operating in the region which may not be transmitting
AIS signals or maintaining a proper lookout

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o A reminder to all crew to contact VTS prior to arrival and departure from the
Sture terminal to establish if there are any reported or unidentified vessels in
the area

o Exercise caution in reliance on VTS in the region for the purpose of

monitoring and safe navigation, until there has been an enquiry into the
actions of VTS in relation to this incident and corrective actions implemented
by VTS

- The shipping company has participated in a full reconstruction of the incident using a
sister Navy frigate and the Sola TS to confirm that the navigation lights of Sola TS
remained visible at adequate/sufficient distance with the Sola TS deck lights on and
that the Sola TS was clearly visible and identifiable as a vessel distinct from the
lighting arrangement of the Sture terminal.

- The shipping company has used the data from the VDR for training purposes.

In addition to the above-mentioned points, the shipping company conducted a review of

the use of deck lights on the Sola TS in light of this incident and on other vessels in their
fleet during departure and arrival operations at night, concluding that:
Sola TS use of deck lights during the incident was appropriate and in accordance with
industry best practice in order to ensure the safety of the crew working on the deck.

The shipping company also concludes that the use of deck lights is not considered to have
contributed to the incident given the two ships’ positions relative to each other and to the
terminal.

1.17.3 The NCA

The Norwegian Coastal Administration has conducted its own investigation of the
accident. The report was not completed at the time this preliminary report was published.

The Norwegian Coastal Administration’s (NCA) internal report on the Vessel Traffic
Service (VTS) identified the following measures:

1.17.3.1 (A) Guidelines for voyages with the Armed Forces’ vessels in VTS areas

It is sometimes necessary to operate the Armed Forces’ vessels without transmitting AIS
information and without the vessels identifying themselves on the VTS centres’ working
channels. Because the VTS centres’ monitoring is largely based on AIS and because full
radar coverage is not available in the VTS areas, more detailed guidelines need to be
drawn up for voyages with the Armed Force’ vessels in the VTS areas.

The NCA and the Navy have started on this work together.

1.17.3.2 (B) Testing of functionality for automatic plotting of vessels not transmitting AIS
information

The VTS centres’ monitoring is largely based on AIS. Functionality for automatic
plotting of vessels is needed in cases where vessels do not transmit AIS information. The
radar system’s existing functionality has previously been tested locally by a VTS centre,
and the conclusion was that the functionality was not sufficiently adapted for operational

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use. On this basis, tests and analyses need to be conducted in order to identify how this
functionality can be improved and adapted to the VTS centres’ monitoring tasks and the
respective VTS areas’ geography and weather conditions.

The NCA has initiated controlled testing of this functionality in cooperation with the
equipment supplier.

1.17.3.3 (C) Improvement of functionality for dead reckoning

The VTS centres’ monitoring system includes functionality for dead reckoning a vessel’s
onward voyage in cases where sensor data from radar and AIS are not available.
Operational use of the system has shown that this functionality needs to be further
developed before it can be used in the VTS centres’ operational monitoring.

The NCA is in dialogue with the equipment supplier on improvement of this

functionality.

1.17.3.4 (D) Criteria for safe passing distance

The VTS areas consist of narrow and open fairways and are used by a number of
different types of vessel. In order to ensure that sufficient margins have been established
in the different VTS areas to avoid undesirable proximity situations, the VTS centres
started a review in spring 2018 of criteria for safe passing distance. The purpose was to
assess whether the criteria take sufficient account of different vessel types and fairways.

The revised criteria are to be described in internal quality documents before the end of
2019.

1.17.3.5 (E) Criteria for information in connection with voyages involving tankers and other large
vessels

In connection with the work on revising criteria for safe passing distances between
vessels, an assessment will also be carried out of the need for revising or drawing up
more specific criteria and procedures for information in connection with voyages
involving tankers and other large vessels. The purpose is to ensure that all vessels have
the same situational awareness in connection with voyages that may require special
considerations by vessels.

1.17.3.6 (F) Requirement for use of English in the VTS areas

The Maritime Traffic Regulations set out as a requirement that the ship’s master or the
officer of the watch as the master’s deputy must be able to communicate in a
Scandinavian language or in English, if the vessel is not under pilotage. The existing
arrangement whereby communication is done in either Scandinavian languages or
English, increases the likelihood of the information being issued in a language that is not
understood by all the navigators involved. Experience from the VTS centres suggests that
consideration should be given to requiring that all communication in the VTS areas is
done in English.

The NCA will propose an amendment of the language provision in connection with the
next revision of the Maritime Traffic Regulations. This must be seen in the context of the

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international guidelines for the VTS centres’ VHF communication which will be
established in 2020.

1.17.3.7 (G) Strengthening of local training

In recent years, the NCA has strengthened central courses and training in the Vessel
Traffic Service and introduced requirements for VTS operators to undergo simulator
training at least twice every five years. A requirement has also been introduced for annual
testing of VTS operators in connection with local authorisation. For the purpose of
further improving training, follow-up and testing of VTS operators, the NCA intends to
strengthen local training resources at the VTS centres, including by reviewing the
structure of local training and follow-up of VTS operators.

During the period January to April 2019, all personnel responsible for local training at the
VTS centres have undergone instructor training.

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2. ANALYSIS
2.1 Introduction

2.1.1 Investigation methods and structure of the analysis

The accident and circumstances surrounding it were investigated and analysed in line
with the AIBN’s framework and analysis process for systematic safety investigations (the
AIBN method). The sequence of events, from the time that HNoMS Helge Ingstad
notified Fedje VTS of entering the VTS area until the accident occurred, was mapped
using a sequential presentation in a STEP43 diagram.

A key question in the investigation has been how and why it was possible for the two
vessels HNoMS Helge Ingstad and Sola TS to collide outside an oil terminal in an area
monitored by a VTS centre. Based on the information that was available immediately
after the accident, the crew and pilot on Sola TS had seen HNoMS Helge Ingstad and
tried to warn of the danger and prevent a collision. Despite this, the crew on HNoMS
Helge Ingstad had not realised that they were on collision course until it was too late. It
was also possible for the VTS centre, Fedje VTS, to influence the situation through traffic
monitoring, information service and traffic organisation.

The analysis in section 2.2 starts with a review and assessment of the sequence of events
from the perspective of the three parties that were directly involved (HNoMS Helge
Ingstad, Sola TS and Fedje VTS), with special focus on the operational and technical
factors that led to each of them being unable to prevent the collision.

Based on its assessment of the sequence of events, the AIBN has investigated and
analysed each of the three parties’ role in and contribution to the situation that arose. The
purpose of the investigation and the analysis has been to ascertain why the accident
occurred, to identify systemic safety problems44 and to report on how safety can be
improved.

2.1.2 Assumptions and reservations relating to the analysis

2.1.2.1 Lack of VDR data for HNoMS Helge Ingstad

There was no VDR on board HNoMS Helge Ingstad, which means that no recording is
available of the communication that took place between the bridge team members on
HNoMS Helge Ingstad. The AIBN therefore points out that the part of the sequence of
events that concerns HNoMS Helge Ingstad is based on a combination of what emerged
in interviews with the personnel involved and data from the frigate’s navigation system,
VDR data from Sola TS and recordings of radio communication.

The AIBN’s assessment concerning VDR coincides with the Armed Forces’ own
conclusion in its investigation of a previous accident (2013) involving a naval vessel (see
section 1.11.10). Had VDR data from HNoMS Helge Ingstad been available, the AIBN
would have had access to unique data to document the sequence of events more exactly,

43
STEP – Sequentially timed events plotting.
44
A systemic safety problem can be described as the investigation’s most important finding with a bearing on safety. It
constitutes a risk factor that the organisation or authorities have some degree of control over and responsibility for, and
which will increase the risk of accidents in the future unless it is dealt with.

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and to better understand the situation on board the frigate. The absence of VDR data did
not contribute to the accident, but it is a factor of such great importance to safety that the
AIBN issues a safety recommendation to the Navy.

2.1.2.2 Limitations of interviews

Information obtained through interviews will necessarily reflect human limitations,

particularly as regards our sensory and memory capacity. People also do not fully
perceive their surroundings all the time, nor do they remember all they have seen, heard
and understood. Interviews are conducted within a limited time period, and sometimes
this can also limit the transfer of information. Furthermore, as time passes, our memory is
affected by who we are and the situation we find ourselves in. The AIBN takes account of
these involuntary limitations of interviewees, and seeks to interview the people involved
and witnesses as soon as possible after the incident, in addition to using data from
different types of sources to confirm or refute information that is based on human
memory.

2.1.2.3 Evaluation of the observation voyage

The observation voyage conducted on board Sola TS and HNoMS Roald Amundsen
during the night leading up to 2 April 2019 (see section 1.15.3) was an important
contribution to the AIBN’s description and understanding of the sequence of events
leading up to the accident.

It is important to keep in mind that night vision and contrast sensitivity may vary from
one individual to the next. The background, training and experience of the observers
varied. They also knew what they were looking for. The quality of the images from the
observation voyage can also result in different and subjective perceptions of the material
being studied.

On the observation voyage, the sky was overcast, humidity was high, and the wind was
strong (moderate gale). The wind blew humidity from the air and smoke from the funnel
on Sola TS forward and downwards, across the tanker’s bridge and onto the floodlights.
Light refraction in the humid air and smoke from the funnel, combined with light
reflection from the cloud cover, may have meant that Sola TS and the surroundings (the
Sture Terminal and the sea’s surface) were seen in a slightly different light than during
the night of the accident.

The manoeuvring performed when leaving the quay and the wind conditions caused Sola
TS to turn towards a northerly course more quickly than the night of the accident (see
Figure 44). This meant that Sola TS was a little closer to HNoMS Roald Amundsen than
planned throughout the observation voyage. The time at which the forward-pointing deck
lights on Sola TS started to stand out more clearly when viewed from HNoMS Roald
Amundsen was probably earlier in the sequence of events than on the accident voyage.

With the exception that Sola TS turned more rapidly to a northerly course, the vessel
followed the same route as on 8 November 2018. HNoMS Roald Amundsen also
followed the same route as HNoMS Helge Ingstad had taken in the early hours of 8
November. During the accident voyage and the observation voyage, the bearings of Sola
TS taken from the frigate were relatively stable and relatively similar. The bearings
changed by approximately 2 degrees in the course of 7–8 minutes of the voyage.

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On the observation voyage, the vessels did not come close enough to each other to enable
observations of what the view from the frigate may have been shortly before the collision.

Figure 44: Left: Sola TS manoeuvring out from the quay on the observation voyage. Right: Sola
TS manoeuvring out from key the night of the accident. Source: NCA/AIBN

Despite the above-mentioned differences between the two voyages, the AIBN is of the
opinion that the observations made in the early hours of 2 April 2019 were representative
and applicable to the analysis part of the investigation.

Nonetheless, the experience gained during the observation voyage cannot be directly
transferred to the situation on board HNoMS Helge Ingstad prior to the accident. Since
the frigate’s bridge team had not identified Sola TS as a moving object, the ‘object’ was
not subject to the same concentrated observation by the bridge team as by the observers
on the observation voyage. None of people involved in the accident were present during
the observation voyage, and they could thus not confirm to what degree the voyage was
representative of the conditions during the night of the accident.

2.2 Assessment of the sequence of events

2.2.1 Introduction

A discussion follows below of the sequence of events from the perspective of the three
players (HNoMS Helge Ingstad, Sola TS and Fedje VTS), and of the factors that
contributed to each of them being unable to prevent the collision.

2.2.2 From the perspective of HNoMS Helge Ingstad

2.2.2.1 Introduction

Navigation training was carried out as usual during transit voyages (this is discussed
further in section 2.3.3.3). The OOWT, who had been on watch since 02:24, had
navigated the frigate from Sognesjøen and was to continue to navigate until they reached
the southern end of the Hjeltefjord. The passage through the Hjeltefjord was not
considered particularly demanding, as the fairway is open and offers a good view all
around. The OOW monitored and controlled the voyage and reported the vessel and
voyage plan to Fedje VTS. The frigate followed the reported voyage plan on the onward
voyage.

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2.2.2.2 03:36–03:53

Sola TS started manoeuvring out from the quay at 03:36, exhibiting navigation lights and
with some of the deck lights turned on to light up the deck for the crew who were
securing equipment etc. for the passage (see section 1.10.4 and 1.10.5). Figure 45 shows
what the situation looked like on the observation voyage when Sola TS started to
manoeuvre out from the quay.

Figure 45: Screenshot of video recording on the bridge of ‘HNoMS Roald Amundsen’ on the
observation voyage in the early hours of 2 April 2019, when Sola TS started to manoeuvre out
from the quay. This corresponds approximately to the situation at 03:36 on the night of the
accident. Sola TS marked with yellow circle. Photo: The police

Until 03:45, all the forward-pointing deck lights were on. At 03:45, the lights in the
midship masts were turned off. After that time, the deck lights just under the bridge deck
and the lights in the foremast remained on Sola TS. The use of deck lights by Sola TS is
discussed further in section 2.4.3.

In daylight, you can see that a vessel is moving in that its position shifts relative to the
shore. Waves from the bow and stern and smoke from the funnel are all observable
indications that a vessel is moving. In contrast to the well of information that is available
to the navigator in daylight, a vessel’s movements at night must largely be ascertained by
observing the vessel’s navigation lights or that the vessel has changed position.

On the observation voyage, the initial manoeuvring out from the quay took place so
slowly that no movement could be observed. It was very difficult to observe the vessel
against the background lights from the terminal, unless binoculars were used and you
knew what you were looking for. The lights from the vessel appeared to be an extension
of the lights from the terminal. Figure 46 shows what the situation looked like on the
observation voyage as Sola TS was moving away from the quay.

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Figure 46: Screenshot of video recording on the bridge of HNoMS Roald Amundsen on the
observation voyage in the early hours of 2 April 2019, seven minutes after Sola TS started to
manoeuvre out from the quay. This corresponds approximately to the situation at 03:43 on the
night of the accident, at which time Sola TS had a more southerly course, however. Sola TS
marked with yellow circle. Photo: The police.

On the observation voyage, Sola TS only stood out clearly as she turned her bow
northwards towards Fedjeosen, so that the forward-pointing yellow deck lights became
visible (see Figure 47). It was difficult, even through binoculars, to discern the vessel’s
navigation lights due to the deck lighting. It was probably during this period that the
relieving OOW and the OOW being relieved on HNoMS Helge Ingstad were discussing
traffic in the fairway. This was when they observed an object giving off masses of light to
starboard of the frigate’s course line, located alongside or near the Sture Terminal. The
‘object’ was observed both visually and on the radar display in the form of a radar echo
and AIS symbol.

Figure 47: Screenshot of video recording on the bridge of HNoMS Roald Amundsen on the
observation voyage in the early hours of 2 April 2019, when Sola TS had turned to a north-
northeasterly course (035°). This corresponds approximately to the situation at 03:49 on the night
of the accident. Sola TS marked with yellow circle. Photo: The police

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The two OOWs stood around the radar together (MFD 1) and observed an AIS signal
from the ‘object’, but no speed vector. Between 03:46 and 03:50, the OOWs changed the
radar settings (by zooming in and out on the display) six times (see section 1.15.2.2).

The OOW being relieved has described that there were two AIS signals. The OOW being
relieved had pressed ‘Data’ and read Sola TS, but saw no other information, such as
SOG/COG (ref. section 1.9.3.9). It is possible that the OOW being relieved made this
observation before the watch handover and before Sola TS moved away from the quay;
the AIBN has been unable to ascertain the time. The observation was in any case not
discussed or mentioned during the OOW handover, or, alternatively, the relieving OOW
did not take note of it. The relieving OOW has described a blue mark, which the OOW
interpreted to be an AIS signal from a fixed installation and not from one or two vessels.
The relieving OOW could not remember having seen or heard the name Sola TS before
receiving the VHF radio call from the pilot on Sola TS.

The OOW being relieved and the relieving OOW discussed whether the lights could
come from a fish farm, a platform or some offshore-related object. This may be related to
the fact that there are fish farms in the area, and that the Hjeltefjord has three major quay
facilities serving the offshore oil and gas industry (see section 1.6.1). The two OOWs did
not clarify the issue. Both OOWs had formed the clear perception that the ‘object’ was
stationary near the shore and thus of no risk to the safety of the frigate’s passage. During
the watch handover, they did not make use of the possibility offered by AIS to obtain
more information about the ‘object’. The OOWs’ statements indicate that, then and there,
they were not aware that there is no vector for sleeping AIS targets. This may have to do
with how AIS symbols are presented on the display (see section 2.3.2.2).

Since the ‘object’ was assumed to be stationary, it was not tracked on the OOW’s radar
(MFD 1). Nor was it tracked on the radar (MFD 2) by the OOWA. As a result of this,
further into the sequence of events, the bridge system did not generate any alarms to
indicate that the vessel was on collision course with Sola TS.

When HNoMS Helge Ingstad entered the Fedje VTS area from the north at 02:50, the
VHF radio was set to channel 80, the VTS centre’s working frequency for the area. But
nobody on board HNoMS Helge Ingstad registered that the pilot on Sola TS notified
Fedje VTS on channel 80 at 03:45 that the tanker would depart the Sture Terminal and set
course for Fedjeosen in the west. This meant that the OOW missed an opportunity to
obtain important information about the traffic situation in the area.

That the radio communication at 03:45 was not registered could be explained by the
following:

- The OOWs had just started the handover procedure and the OOWT was focusing on
navigating the vessel. The OOWT has also stated that it was the OOW who usually
monitored the VHF radio, as the communication was most often conducted in
Norwegian (see section 2.5.5).

- The traffic information was not provided by Fedje VTS (see section 2.5.3).

- As far as the AIBN has found, none of the messages from Sola TS to the Maritime
Traffic Center over VHF channel 80 were registered at HNoMS Helge Ingstad. This
may be related to how an operator registers and filters the communication that takes
place on the radio (see section 2.3.2.7).

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2.2.2.3 03:53–03:59

After the watch handover on the bridge at 03:53, the relieving OOW’s further decisions
and actions relied on the situational awareness that the ‘object’ at the Sture Terminal was
stationary. The investigation has demonstrated that it was difficult to rectify this
awareness based on visual input alone.

Viewed from HNoMS Helge Ingstad, the deck lights on Sola TS did not give the
impression of a moving vessel. On the observation voyage, the lights appeared to increase
in intensity as the vessels came closer to each other, but it was nonetheless difficult to
judge the distance. Furthermore, the intensity of the lights was dazzling, and it was
unpleasant to look straight at them.

Figure 48: Top: Screenshot of video recording on the bridge of HNoMS Roald Amundsen on the
observation voyage in the early hours of 2 April 2019. This corresponds approximately to the
situation at 03:53 on the night of the accident. Bottom left: Screenshot of video recording on the
bridge of Sola TS on the observation voyage. Bottom right: Screenshot of video recording of the
radar display on HNoMS Roald Amundsen on the observation voyage, marked with white circle.
Sola TS marked with yellow circle. Illustration: The shipping company/police/AIBN

The photo in Figure 48 shows what Sola TS may have looked like from the bridge of
HNoMS Helge Ingstad at around 03:53 on the night of the accident. The figure also
shows what HNoMS Helge Ingstad may have looked like from the bridge of Sola TS,
marked with a white circle. As evident from the image in the bottom right corner, Sola
TS was visible on the radar on board HNoMS Helge Ingstad at this time.

The OOW was focusing on the three vessels approaching in the opposite direction on the
port side of HNoMS Helge Ingstad, which had been observed visually and tracked in the
bridge system.

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Data from the bridge system show that the settings on the OOW’s radar (MFD 1) were
changed from 3 nm to 6 nm and back to 3 nm at 03:55 (see section 1.15.2.2). It was
probably the OOW whom at this time checked whether there were more vessels further
ahead. Figure 49 shows the radar display on HNoMS Roald Amundsen on the
observation voyage, at a time approximately corresponding to 03:55 on the night of the
accident, with the range scale set to 3 nm on the left and to 6 nm on the right.

Figure 49: Screenshot of video recording of the radar display on HNoMS Roald Amundsen
during the observation voyage in the early hours of 2 April 2019, with the range scale set to 3
nm on the left and to 6 nm on the right. This corresponds approximately to the situation at
03:55 during the night of the accident. Photo: The police

After having checked the radar, the OOW informed the bridge watch team that they
would pass three vessels approaching in the opposite direction, and asked them to notify
of any further observations. The OOW did not mention the ‘object’ at the Sture Terminal
since the two OOWs had assumed that it was stationary. The OOW did not have an
overview of the names of the three approaching vessels. A little later, on receiving a call
from the pilot on Sola TS, the OOW thought it came from one of the vessels approaching
in the opposite direction that was requesting them to change course to starboard.

In the period 03:56-03:59, a total of five alarms on MFD 1 and MFD 2 related to vessels
on the frigate’s port side were acknowledged. This probably contributed to draw the
bridge crew’s focus towards these vessels (see section 2.3.7.2).

During the period leading up to the collision, the position of starboard lookout (STBD
LO) was unmanned (see section 2.3.2.4). At the same time (03:52–03:57), the two
trainees (OOWT and OOWAT) were engaged in optical positioning. There was also a
watch change for the OOWAs during this same period. Hence, during the decisive period
leading up to the collision, there was reduced capacity in the bridge team to monitor the
traffic situation. The organisation of the bridge team is discussed further in section
2.3.8.2.

2.2.2.4 03:59–04:00

The OOW on HNoMS Helge Ingstad eventually noticed that the ‘object’ on the starboard
bow seemed to be closer to the frigate’s course line than first assumed, leaving less
distance to the closest point of approach. The OOW has stated that the ‘object’ was
primarily observed visually, but the OOW had also seen on the radar that there was a

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little distance between the shore and the ‘object’. The AIBN’s understanding is that the
OOW was still under the impression that this was a stationary object close to the Sture
Terminal, that there was no room to pass between the ‘object’ and the terminal, and that
the distance between the shore and the ‘object’ could be explained by the frigate having
come closer to the point at which the ‘object’ lay alongside.

The OOW thought that the course would have to be adjusted slightly to port to increase
the passing distance to the ‘object’. The OOW could not make a wide turn to port,
however, as this would create a proximity situation with the vessels approaching in the
opposite direction on the port side of the frigate.

Data from the bridge system show that the settings on the OOW’s radar (MFD 1) were
changed from 3 nm to 1.5 nm at 03:59 (see section 1.15.2.2). This was probably done by
the OOW to check that there was room to adjust the course towards port without
conflicting with the three approaching vessels. The OOW instructed the OOWT to adjust
the course by some degrees to port. During the period up until the time of the collision,
the course of HNoMS Helge Ingstad was adjusted by a total of 10 degrees to port through
a series of small course changes (see section 1.15.1.2).45

Figure 50 shows a screenshot of a video recording of the radar display on HNoMS Roald
Amundsen on the observation voyage, with the range scale set to 1.5 nm at a time
approximately corresponding to 03:59 during the night of the accident.

Figure 50: Screenshot of video recording of the radar display on HNoMS Roald Amundsen during
the observation voyage in the early hours of 2 April 2019, with the range scale set to 1.5 nm. This
corresponds approximately to the situation at 03:59 on the night of the accident, when the
distance between Sola TS and shore (Ådnesflua) was approximately 950 meters. Photo: The
police

45
According to the COLREGS one shall go starboard of approaching vessels and avoid a series of small course
changes. The OOW did not relate to this, since the ‘object’ to starboard was perceived as being stationary near the
shore, rather than a vessel.

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As shown in Figure 50 at this time the distance between land and the ‘object’ was 950 m.
The distance between the ‘object’ and the first of the three northbound vessels was
approximately half of this. The OOW’s situational awareness, radar use, experience and
competence are discussed further in sections 2.3.2.2 and 2.3.3.2.

On the observation voyage, as Sola TS turned towards a northerly course, it was observed
that the yellow floodlights stood out clearly as representing a separate entity not
connected to the Sture Terminal, but that it was difficult to discern the contours of a
vessel behind the deck lights. Other lights or navigation lights on the vessel were not
visible to the naked eye. On the other hand, it proved possible on the observation voyage
to distinguish the sidelights though the binoculars when concentrating on looking for
them. The AIBN has not found that the bridge team used binoculars to study the ‘object’
during this period of the night of the accident.

Nobody on the bridge of HNoMS Helge Ingstad reported having seen the navigation
lights or the three red top lights on Sola TS. They only observed the strong deck lights on
Sola TS. Of those present, only the HM reported having identified the ‘object’ giving off
light as a vessel. This is discussed further in section 2.3.2.6.

2.2.2.5 03:59–04:01

The OOW on HNoMS Helge Ingstad answered the direct call on VHF channel 80 from
the pilot on Sola TS immediately. On hearing HNoMS Helge Ingstad being mentioned by
name on the VHF radio, the OOW moved approximately 1.5 m to the VHF radio to
answer the call (see section 2.3.7.4).

When the OOW, at 04:00:11, responded by saying that they could not turn to starboard,
this was based on the firm perception that the floodlights observed by the OOW came
from a stationary object close to shore and that it was not a vessel, that there was not
enough room to pass on the shore side of the ‘object’. Furthermore, the OOW assumed
that it was one of the three northbound vessels approaching to port that was requesting
the frigate to alter course to starboard, as the OOW had just adjusted the course to port.
The OOW did not recognise the name Sola TS, and, as mentioned above, had not
checked the names of the three vessels approaching in the opposite direction on the radar.

The manner in which the OOW replied to the VHF call indicates that the OOW felt
certain of the situation and was under the impression that they were steering a good
middle course between the ‘stationary object’ and the approaching vessels. However, the
OOW’s reply that they could not turn to starboard before they had passed what the OOW
referred to as the ‘blocks/sea marks’ and subsequently the ‘platform’ indicates that the
OOW was not sure what the frigate was passing.

Since it was perceived as being stationary, neither the OOW nor the OOWA had tracked
the ‘object’ on their respective radar displays. No alarm was therefore generated to
indicate that they were too close to Sola TS. Since automatic vessel detection would
generate many pointless and distracting alarms in inshore waters, this function was
normally deactivated. This meant that no technical barrier had been activated to warn of
or prevent collision.

The OOW received the call from Sola TS with the request to change course
approximately one minute before the vessels collided. Had the OOW become aware of
the situation, assessed it correctly, decided how to manoeuvre and ordered full rudder to

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starboard no later than 38 seconds prior to the time of the collision, the collision could
have been prevented (see section 1.15.4). However, the OOW had not become aware of
the situation by that time.

When the OOW understood that the ‘object’ giving off light was moving and on direct
course to collide, it was too late to avoid the collision. The only option left to the OOW
was to try to manoeuvre around the bow of Sola TS. Realising that it was too late to turn
to starboard at the time, the OOW therefore ordered rudder 20 degrees to port, and then
rudder midship immediately afterwards. Given the available time this was probably a
reasonable manoeuvre, since a turn to starboard must have been carried out earlier.

2.2.3 From the perspective of Sola TS

Sola TS started manoeuvring out from the quay at 03:36. From approximately 03:50, Sola
TS set the planned course towards Fedjeosen. At this point in time, there was a distance
of approximately 4 nm between the vessels. Neither HNoMS Helge Ingstad nor any other
vessels were plotted on the radar on Sola TS. The bridge team did not raise any questions
about or discuss the other vessels in the vicinity. The bridge team cooperation under
pilotage is discussed further in section 2.4.2.

Shortly before Sola TS had turned to a northerly course, the pilot observed the
southbound vessels without being aware at the time that one of them was HNoMS Helge
Ingstad. The pilot reacted when the vessel was getting closer without indicating that it
would give way. This was approximately four minutes before they collided, at which
point the distance between the vessels was approximately 1.5 nm. At 03:57:25, the pilot
requested AIS data about the southbound vessel from the master on Sola TS. However,
HNoMS Helge Ingstad did not transmit AIS-data (see section 2.3.9). The vessel’s name
was therefore not displayed to the master on Sola TS. This probably raised the threshold
for contacting the vessel directly.

At 03:58:03, the pilot on Sola TS called Fedje VTS on VHF channel 80, requesting
information about the vessel. At 03:58:30, Fedje VTS answered that they were also
unable to identify the vessel (see section 2.2.4).

From 03:59, Sola TS tried to establish contact with the vessel using the Aldis lamp. The
visibility of the flashes was reduced by Sola TS deck lights, however, and were therefore
not perceived by the bridge team on HNoMS Helge Ingstad. Both the master and the pilot
have stated that, shortly after signalling with the Aldis lamp, they were briefly able to
observe both sidelights on HNoMS Helge Ingstad and thought that the vessel was turning
to starboard, which was also what they expected. Technical information from the
navigation system at HNoMS Helge Ingstad, indicates that the vessel was keeping a
stable course during this period. Measurements conducted by the Navy, of the lanterns at
HNoMS Helge Ingstad and HNoMS Roald Amundsen indicates that it cannot be
excluded that both lanterns may have been visible in this period the night of the accident.
However, the Accident Investigation Board considers that this has not changed the
sequence of events and therefor does not discuss this further.

The option of using other means to establish contact with the frigate, such as the fog horn
or a general call to all southbound vessels in the Hjeltefjord, is discussed further in
section 2.4.4.

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At 03:59:21, Sola TS initiated a course change from 350° to 000°, i.e. 10° to starboard, to
indicate an evasive manoeuvre to the approaching vessel. The pilot on Sola TS also had
to take account of there being vessels on the starboard side of the tanker. The ordered
course change turned the bow of Sola TS 10 degrees to starboard, but the tanker’s course
over ground had in reality not changed much before the two vessels collided. At the same
time as Sola TS altered course to starboard, HNoMS Helge Ingstad made several small
course changes to port.

A period of 2.5 minutes passed from the time that the pilot requested AIS data of the
approaching vessel from the master until contact was established with HNoMS Helge
Ingstad. When the pilot on Sola TS was told by the VTS operator on VHF channel 80 that
the approaching vessel was HNoMS Helge Ingstad, the pilot immediately called the
frigate. The OOW on HNoMS Helge Ingstad answered the call immediately, at 04:00:02,
a little over a minute before the collision occurred.

The fact that HNoMS Helge Ingstad could not be identified by means of AIS and the lack
of monitoring on the part of Fedje VTS caused valuable time to be lost – time during
which the frigate could have been warned of the vessels being on collision course.

The OOW on HNoMS Helge Ingstad was not aware that the illuminated ‘object’ up
ahead was Sola TS, the vessel the OOW was communicating with. Nor did the
communication between Sola TS and HNoMS Helge Ingstad help to change the OOW’s
situational awareness. This will be discussed in more detail in section 2.4.5.

When HNoMS Helge Ingstad did not change course, the master on Sola TS ordered ‘stop
engines’ and, 20 seconds later, the pilot ordered full speed astern on the engines. These
two measures were carried out a short time before the collision and were therefore
without material effect. The escorting tugboat was not ordered to assist in reducing the
tanker’s speed or changing her course. So close to the time of collision, such measures
would probably also have been without material effect.

2.2.4 From the perspective of Fedje VTS

At 02:38, the OOW on the 00–04 watch notified Fedje VTS that HNoMS Helge Ingstad
was entering the VTS area from the north, and informed of the planned onward route.
The VTS operator at Fedje VTS logged HNoMS Helge Ingstad, but did not plot the
frigate on the radar. Nor was HNoMS Helge Ingstad plotted on the radar after it had
crossed the boundary to the Fedje VTS area at 02:50, and the time of entering the traffic
area was not logged. The VTS centre’s practice relating to the plotting and monitoring of
vessels is discussed further in section 2.5.2.

At 03:13, the pilot on Sola TS called Fedje VTS on VHF channel 80 with the message
that they were starting to take in the mooring lines and preparing to depart from the Sture
Terminal. Fedje VTS acknowledged receipt of the message. There was little vessel traffic
in the vicinity of the Sture Terminal, and the VTS operator saw no need to inform other
vessels in the area at the time. The three northbound vessels were 6.5 nm south of the
Sture terminal. HNoMS Helge Ingstad was approximately 14 nm north of the terminal.
Furthermore, the VTS operator did not know when the tanker would leave the Sture
Terminal. This is discussed further in section 2.5.3.

At 03:45, the pilot on Sola TS notified Fedje VTS on VHF channel 80 that the tanker was
departing from the Sture Terminal and heading west out Fedjeosen. By this time, traffic

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was becoming denser in the area off the Sture Terminal. Fedje VTS confirmed receipt of
the information, but did not organise traffic in any way or issue information to vessels in
the area relating to the departure of Sola TS (see section 2.5.4). The radio communication
was in Norwegian (see section 2.5.5).

Fedje VTS had not monitored the passage of HNoMS Helge Ingstad after the frigate
notified of entering the area. When Fedje VTS received a call from the pilot on Sola TS
on VHF channel 80 approximately 3 minutes before the collision, requesting information
about the vessel that was approaching head on, the operator at Fedje VTS was unable to
answer immediately. HNoMS Helge Ingstad was not transmitting AIS signals and had not
been plotted on Fedje VTS’s radar. The VTS operator only saw the frigate as an echo on
the radar screen, without direction/speed vector. The VTS operator immediately plotted
the frigate and became aware of the collision danger. The VTS operator did not
remember, however, that HNoMS Helge Ingstad had notified of entering the area from
the north earlier that night (at 02:38). This, in turn, meant that valuable time for notifying
HNoMS Helge Ingstad that they were on collision course was lost.

Approximately 1.5 minutes later, the VTS operator remembered HNoMS Helge Ingstad.
The VTS operator passed this information on to the pilot on Sola TS over VHF channel
80. Once the vessels had established contact, the VTS operator assumed that they would
resolve the situation between themselves, and left it to the pilot on Sola TS to clarify the
situation (see section 2.5.4).

2.3 The frigate HNoMS Helge Ingstad and the Navy

2.3.1 Introduction

The following topics are addressed in this section on HNoMS Helge Ingstad and the
Navy: the bridge team’s situational awareness, level of experience, training and
competence, the organisation of and BRM in the bridge team, fatigue and functional
capacity, reduced visual functions, the frigate’s navigation aids, the bridge manual and
bridge design, and the Navy’s use of AIS.

Among other things, our assessment is based on the sequence of events, interviews with
the bridge personnel, the Navy’s governing documents for Fridtjof Nansen-class frigates,
the frigate’s navigation aids, and research and theory related to human
functioning/limitations and situational awareness.

2.3.2 The bridge team’s situational awareness at the individual level

2.3.2.1 General observations about situational awareness

In order to assess the bridge team’s functioning, the AIBN has used the situational
awareness of each individual member prior to the collision as a point of reference.
Situational awareness is defined in Appendix G and can be broken down into three levels:
Level 1 – perception of the elements in the environment, Level 2 – comprehension of the
relationship between these elements, Level 3 – projection of future developments and
events (Endsley, 1995).

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2.3.2.2 The officer of the watch (OOW)

In addition to safe navigation, the OOW was responsible for organising the bridge team
and for satisfactory training of the OOWT and the OOWAT. The OOW’s actions while
present on the bridge during the minutes before the collision were based on the available
information, which primarily consisted of:

- The watch handover between the OOWs: As described in section 2.2.2.2, both OOWs
were under the clear impression that the ‘object’ at the Sture Terminal was stationary,
and that it was something other than a vessel and therefore did not pose any risk to
the frigate’s passage. They therefore did not use the possibility offered by AIS to
obtain more information about the ‘object’. The OOW being relieved had read Sola
TS at some point, but either did not pass on this information or the relieving OOW
did not take note of it.

- Presentation of AIS symbols: The relieving OOW has described a blue mark. This
was interpreted to be an AIS signal from a fixed installation and not from one or two
vessels. Since HNoMS Helge Ingstad had not tracked Sola TS, the tanker will have
been represented by the symbol for a sleeping AIS target (see section 1.9.3.8). The
tugboats assisting Sola TS will also have been presented as sleeping AIS targets.
Since the symbol orientation depends on the bow orientation, Sola TS and the
tugboats may have been entangled on the MFD display on HNoMS Helge Ingstad, so
that they appeared to represent a navigation object or a virtual navigation object (see
Figure 51).

Figure 51: On the left: Screenshot of video recording of radar display on HNoMS Roald
Amundsen on the observation voyage. Sola TS with escorting tug marked with a white circle.
Virtual navigation object in the top right corner. Navigation object, landmark or buoy with AIS
transponder in the lower right corner. Illustration: AIBN

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- Optical information observed by the OOW through the bridge windows after taking
over the watch: The forward-pointing deck lights on Sola TS made it difficult, even
through a pair of binoculars, to discern the vessel’s navigation lights. The visual
impression was that the ‘object’ was not a vessel, but an object giving off light close
to the Sture terminal. As the tanker moved into the fjord and the distance between
Sola TS and the terminal gradually increased, VS had shifted their attention to
ensuring a good passage of the three vessels up ahead that were approaching to port,
monitoring of the training activity on the bridge and otherwise following up that the
voyage took place according to plan. The OOW therefore did not detect the
movement of Sola TS visually, and did not rectify the misperception of a stationary
‘object’ near the shore. The OOW eventually thought that the course would have to
be adjusted slightly to port to increase the passing distance to the ‘object’. It was
difficult to estimate the distance to the ‘object’ due to the darkness and the tanker’s
lights. The AIBN considers it likely that the OOW estimated the distance to the
‘object’ based on perceived distance from the flood lights. The bow of the tanker,
which was approximately 200 m closer to the frigate than the strongest deck lights,
was probably not perceived by the OOW until just before the collision.

- Information from the bridge system: The OOW has stated that the situation after the
watch handover did not appear to warrant any active radar use. After the watch
handover, the OOW used the radar to verify what the OOW observed through the
bridge windows and the OOW did not study the radar thoroughly during the sequence
of events. Primarily, the OOW used the radar to verify the movements of the three
vessels up ahead that were approaching to port. The alarms also contributed to draw
the attention towards these vessels (see section 2.3.7.2). The radar echo from Sola TS
on MFD 1 (see Figure 49) was probably filtered away in the OOW’s registration and
prioritisation of sensory inputs, as the OOW’s focus was elsewhere. The OOW
eventually noticed that the ‘object’ on the starboard side seemed to be closer to the
frigate’s course line than the OOW had first assumed, leaving less distance to the
closest point of approach. The OOW has stated that the ‘object’ was primarily
observed visually, but the OOW had also seen on the radar that a little distance had
appeared between the shore and the ‘object’ (see Figure 50). The OOW was still
under the impression that this was a stationary object outside the Sture Terminal, and
that the distance between the shore and the ‘object’ on the radar screen could be
explained by the frigate having come closer to the point at which the ‘object’ lay
alongside the shore. Hence, the OOW interpreted the information in a way that
upheld the OOW’s situational awareness.

- Information received by the OOW over the VHF radio: When the pilot on Sola TS
was told by the VTS operator that the approaching vessel was HNoMS Helge Ingstad,
the pilot immediately called the frigate. The pilot’s communication was not
sufficiently detailed, however, to rectify the OOW’s prevailing situational awareness.
This is discussed further in section 2.4.5.

- Information from the previous day’s voyage planning: The electronic chart did not
contain any information in the form of comments on the possible presence of tankers
approaching or leaving the oil terminal or on dangers to keep in mind when passing
through the area. Voyage planning is discussed further in section 2.3.8.3.

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- The information received from the rest of the bridge team gave no indication to the
OOW that the ‘object’ had moved away from shore and was on collision course with
the frigate. This is discussed further below.

The OOW was under the clear impression of being in control of the onward voyage and
focused on ensuring that the three vessels approaching to port in the opposite direction
could be passed safely. The OOW did not give priority to monitoring the ‘object’, having
decided that it did not constitute a threat to the frigate.

In the beginning of the watch, the visual distance, seen from the frigate’s bridge, between
the approaching vessels and the Sture terminal was approximately 1200 m. The OOW
had the clear perception that the illuminated ‘object’ was stationary near the shore and the
situation, as perceived by the OOW, gave no reason to reduce the frigate’s speed. This
situational awareness was maintained by the OOW until just before the collision.

Research shows that, intuitively and without being aware of it, people often tend to seek
confirmation of their own initial situational awareness. Although it cannot be verified,
this may have contributed to the OOW not detecting the danger of collision in time. It
may be that the OOW interpreted the visual input through the bridge windows as
confirmation that the frigate had three approaching vessels to port and one stationary
‘object’ near the shore to starboard. The OOW has explained that the lights growing
slowly stronger was completely in line with the perception that the frigate was drawing
closer to the ‘stationary object’. This type of confirmation bias can easily arise in a
complex situation like the one being considered here; see the research described in
Appendix G.

The investigation has shown that the information received and sought by the OOW
(Level 1) was not sufficient to help the OOW get a correct understanding of the situation
(Level 2) in the space of time that the OOW was on the bridge before the collision.
Hence, it was not possible for the OOW to predict the danger of collision (Level 3) and
take action to prevent collision.

2.3.2.3 Officer of the watch trainee (OOWT)

The mode of navigation on HNoMS Helge Ingstad on this voyage was ‘electronic
positioning with a combination of optical and radar control’. On this particular night, the
OOWT had been set the specific task of practising checking the vessel’s position on the
electronic chart (ECDIS) using optical navigation aids. At the same time, the OOWT was
to carry out all the tasks normally seen to by an OOW. The OOWT was to navigate the
frigate, including in relation to other vessels in the fairway, and to perform course
changes by issuing orders to the helmsman. The role of the OOW was to ensure a safe
voyage, and to guide and correct the OOWT as necessary. Even though the frigate was
being navigated by the OOWT, it was the OOW who was responsible on the bridge.

During the OOW handover between 03:45 and 03:53, the OOWT was navigating the
vessel and did not pick up on the OOWs’ discussion about the ‘object’. The OOWT had
observed the lit object and seen it as being one with the shore at the Sture Terminal, but
had neither identified it as a vessel nor checked it out on the radar. During the same
period (03:38–03:56), the OOWT and the OOWAT performed several optical position
determinations to verify that the ECDIS positions were good. In practice, this meant that
the OOWT took bearings of different objects using the pelorus at the centre of the bridge.

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The bearings were communicated to the OOWAT, who plotted them on the frigate’s
ECDIS to determine the frigate’s position (see section 1.15.2.3).

It seems clear to the AIBN that, during the period leading up to the collision, optical
positioning and operating the bridge equipment took most of the OOWT’s attention. This
meant that less attention was given to other OOW tasks, such as keeping an overview of
the traffic situation.

2.3.2.4 The lookouts (STBD LO and PORT LO)

The bridge watch team, which consisted of three conscripts, had a supporting role in
relation to the OOW and OOWT. The lookouts are tasked with looking out for relevant
information, vessels and other potential dangers to navigation, and notifying the OOW of
their observations. They must also carry out any orders issued by the OOW.

The starboard lookout position was unmanned from 03:41 until 03:59 as a consequence
of the bridge team, by agreement with the OOW being relieved, taking turns to go down
for a night meal. This meant that a barrier was weakened during a period when Sola TS
could have been identified as a vessel on collision course. I-200 Instruks for brotjenesten
(‘Bridge service instructions’) states that ‘When only one lookout is present on the bridge,
the lookout shall look out on the starboard side’. In this case one cannot say for certain
whether it would have made any difference whether the lookout had been standing on
starboard side, as visibility in the fairway ahead was good from both lookout positions on
the frigate. Based on the PORT LO’s statement, the PORT LO focused mainly on the port
side and the three vessels approaching in the opposite direction, after having taken a
quick look at the surroundings through the binoculars and assumed that the ‘object’ on
the starboard side was a quay. Immediately after the collision, the PORT LO still thought
that the frigate had collided with a quay.

On returning to the bridge at 03:59, the STBD LO also did not see any navigation lights
and thought the ‘object’ giving off light might be a quay. It was not until the strong lights
came even closer and the STBD LO heard it being said on the radio that they must do
something that the STBD LO understood that it was a vessel on collision course. It is
difficult to determine exactly when the STBD LO understood this, but it may have been
around the same time that the OOW realized that the illuminated ‘object’ was moving.
Hence, it was too late for the STBD LO act upon the situation.

2.3.2.5 The officer of the watch assistant (OOWA) and officer of the watch assistant trainee
(OOWAT)

It seems clear to the AIBN that, during the period leading up to the collision, both the
OOWA and the OOWAT, like the OOWT, directed most of their attention to optical
positioning.

The relieving OOWA, who took over the watch at 03:56, has stated that there was a lot of
light on the starboard bow from something that the OOWA thought was a square
platform. The OOWA did not consider it a danger to the frigate and therefore did not
check it out on the radar (MFD 2). Much of the OOWA’s attention was focused on
training the OOWAT in primary tasks, which, according to the watch plan, were ‘to
operate MFD 3, where he is responsible for monitoring and correcting the voyage by
continually informing the officer of the watch about time and distance to turn, next

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course, headings, turn objects, passing distances etc. in accordance with applicable
procedures’.

The AIBN believes that, since the OOWAT was a novice to bridge duty, most of the
OOWAT’s attention was taken up with operating MFD 3 and cooperating with the
OOWT on optical positioning. The OOWA focused on ensuring that the OOWAT learnt
as much as possible.

The training activity competed for attention with the OOWA’s secondary tasks, which
were to ‘operate and monitor MFD 2 with the emphasis on information about other
vessels’. This meant that the safety function that the OOWA could have constituted
through operating important systems and assisting the OOW/OOWT was not in place.

2.3.2.6 The helmsman (HM)

The interviews conducted by the AIBN indicated that the helmsman realised before
anybody else in the bridge team that the lights ahead on the starboard side of HNoMS
Helge Ingstad belonged to a moving vessel.

The HM assumed that the OOW and OOWA were aware of it being a vessel as they
would have been able to observe it on AIS and radar, in other words that they were in
control of the situation through having access to the bridge system. The HM also thought
that the rest of the bridge team had likewise understood that this was a vessel. At the
time, the HM also thought that the lookout had notified of this vessel as well as the three
vessels approaching to port.

The HM’s attention was directed at the HM’s primary tasks, see the helmsman’s
instructions (I-209.01), which were to man the wheel and receive and act on the orders of
the OOW/OOWT. The HM focused on the rudder indicator and the frigate’s heading, and
on keeping a steady course. The HM only glanced out through the window occasionally
and did not have a complete overview of the traffic situation. The HM had not been
instructed to warn of any vessels the HM detected that several other members of the
bridge team were tasked with detecting; the lookouts have this as their primary task, and
the OOWA has it as a secondary task, something that the HM was aware of.

The HM has described that it was difficult to see what course the vessel had, both
because it was very dark and because the HM only briefly glanced up from the rudder
indicator. According to the HM, when the vessel came closer, it appeared at first to be a
straight-forward starboard-to-starboard passing. The HM assumed at the time that this
was what the OOW/OOWT planned to do. But just before they collided, the HM realised
that the vessel was on collision course with the frigate. At that point, the HM became
worried, stood up and was ready to take rudder orders from the OOW. The HM did not
have the same professional skills as the OOW in navigating and manoeuvring a vessel,
and, according to the HM, this was another reason why the HM did not request a
clarification of the situation from the OOW. The AIBN considers that the HM performed
the HM’s duties in accordance with what can be expected of a conscripted member of the
bridge team.

2.3.2.7 Attention, filtration of sensory inputs and change blindness

That neither the OOW, the OOWT nor the OOWA took note of the radar echo from Sola
TS may have to do with the way the human sensory system is built up and functions. Our

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capacity to register and understand sensory inputs is limited. This means that many
situations, particularly under challenging operational circumstances, can only be tackled
if you focus on the information perceived as important there and then, and filter from
your awareness information that is irrelevant to the performance of the task at hand.
These are necessary and everyday processes in human functioning.

We know from research into road safety that drivers are often blind to unexpected road
users. This is often described in the literature as ‘looked, but failed to see’. Chabris and
Simons (2011) coined the phrase ‘inattentional blindness’ to describe this blindness to the
unexpected.

The phenomenon can be explained by selective attention control (see Appendix G).
Those involved do not notice special or unexpected events because their attention is
focused on one task in such a way that other situational elements are filtered from their
awareness. The overall picture, and any changes to the overall picture, do not become
part of their continuously updated situational awareness.

The perception of new visual information from the environment will largely depend on
awareness of the actual change. The size and speed of the new element will determine
whether the shift is great enough to make us aware of the change. A slow change in a
small part of the field of vision is difficult to detect, while a quick shift in a large part of
the field of vision is naturally easier to detect. There is a lower threshold for becoming
aware of such changes, which varies from one person to the next.

When Sola TS first started manoeuvring away from the quay, this was done so slowly
that it was difficult to register any movement. It was demonstrated on the observation
voyage that, for a relatively brief period (03:49–03:51), it was possible to observe how
the deck lights changed when the tanker turned northwards. During that period, the bridge
team’s attention was probably directed at optical positioning and the OOW handover.
After Sola TS came on a course towards HNoMS Helge Ingstad, the distance to the
’object’ became smaller, without the ‘object’s’ movement being easy to detect. At the
same time, the distance slowly increased between the ’object’ and the shore. The OOW
had observed this, but was unable to interpret it correctly (see section 2.3.2.2).

The OOWT was largely concentrating on cooperating with the OOWAT on optical
positioning. The OOW had a clear impression of being in control of the onward voyage
and focused on ensuring that the three vessels approaching to port in the opposite
direction could be passed safely. Neither officer gave priority to monitoring the ‘object’
at the Sture Terminal. This meant that they both depended on a shift in awareness from
what they were focusing on to the radar echo of Sola TS, or a rapid change in the
environment relating to Sola TS of a magnitude great enough to attract their attention. As
we know, there was no such event or warning. On the contrary, the alarms that went off
contributed to maintaining focus on the vessels on the port side (see section 2.3.7.2).

During the watch handover, the OOW being relieved and the relieving OOW did not use
the possibility offered by AIS to obtain more information about the ‘object’. There may
have been an element of economising on mental capacity when the OOW ‘decided’ that
the ‘object’ was stationary, and did not consider ‘what if’ or ask anyone to pay particular
attention to the ‘object’ until they had passed it. Even when we have surplus capacity, we
continue to employ economising mechanisms as long as possible, even if the utility value
and quality of our choices are sub-optimal (see Appendix G).

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The OOW's location on the bridge was for the most part close to the VHF radio and radio
communication could be heard from this location. In the AIBN’s opinion, communication
on VHF radio is something an operator will register, but may not always process further
if the message does not matter or is not addressed to the vessel. Clear message markers
(for example, "warning" or "mayday") and calls to your own vessel, on the other hand,
will catch your attention. When the OOW heard HNoMS Helge Ingstad mentioned, the
OOW responded immediately.

2.3.3 Level of experience, training and competence

2.3.3.1 Introduction

Research by Endsley et al. has shown that situational awareness is affected by experience
and expertise. Research also indicates that less experienced people clearly have less
capacity than experienced people for picking up on weak signals of danger (Hærem &
Rau, 2007).

The relieving OOW had held clearance as officer of the watch for eight months when the
accident occurred. The OOW led a team consisting of young conscripts with limited
maritime experience, at the same time as training was in progress for two watchstanding
functions (OOWT and OOWAT).

The question can be raised as to whether a more experienced OOW might have been able
to draw on a wider repertoire for recognising signs that Sola TS was moving, and perhaps
also been more persistent in the effort to clarify the ‘object’s’ status. This is discussed
further in section 2.3.3.2.

The investigation has shown that the training activity that was being conducted on the
bridge on the voyage in question, took a lot of the bridge team’s attention. The Navy’s
guidelines for such training activity are discussed in section 2.3.3.3.

The OOW had advanced on the career ladder relatively fast and had little experience in
relation to the responsibility associated with the position on board. This is discussed in
connection with the career path and experience level for OOWs in general and the Navy’s
need for vessel crews in section 2.3.3.4. A discussion of the quality assurance of the
navigation team’s competence follows in section 2.3.3.5.

2.3.3.2 Assessment of the level of experience as a factor in the accident

In the AIBN’s opinion, the level of experience in navigating inshore waters at night had a
bearing on the ability to assess the situation with Sola TS correctly based on optical
information alone. That the HM, who was not a navigator, nonetheless recognised the
‘object’ as a vessel may have been a matter of chance, for example that the HM was the
only person on the bridge who observed the ‘object’ during the period when it was easier
to recognise it as a vessel. This is difficult to verify after the event.

A more experienced navigator would have been better equipped to recognise the ‘object’
alongside the Sture Terminal that night as a tanker, and would probably have had more
experience of encountering big outbound oil tankers leaving oil and gas terminals, both in
daylight and at night. In the AIBN’s opinion, an experienced navigator would have been
more capable of interpreting radar images and AIS symbols correctly and, if applicable,
to use the bridge system more effectively.

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All in all, the sequence of events suggests that the level of experience had a bearing on
the accident. As mentioned by way of introduction, research indicates that less
experienced people clearly have less capacity than experienced people for picking up on
weak signals of danger. A more experienced navigator would have been better equipped
to suspect that his/her own situational awareness was inaccurate, based on having more
experience of similar situations (the recognition effect). A possible and natural reaction
would then be to reduce the speed, and thus have more time to analyse the situation and
take action.

2.3.3.3 Training activity on the bridge

Operative personnel without OOW clearance are always present on board and navigation
training therefore takes place whenever an opportunity arises. Several of those who were
interviewed by the AIBN considered that voyages were safer with than without an
OOWT on the bridge. It gives the OOW a better overview and more control of the
situation, as well as an extra pair of eyes and an extra person to monitor the radar. The
OOW has explained, however, that it can also make the OOW more distant in relation to
the systems, since the OOWT can concentrate fully on the tasks and tends to adopt a
more hands-on approach to the radar and chart.

The AIBN’s review of the sequence of events shows that the navigation training
involving two trainees on the voyage under consideration drew parts of the bridge team’s
attention away from the overall traffic situation. As a result of the training activity, the
OOW/OOWT lacked assistance from the OOWA to operate important bridge systems. It
also meant that there was less direct communication between the OOW and the OOWA.
The OOW also used some capacity to monitor the training activity. At the same time,
attention was directed at the three vessels approaching to port in the opposite direction,
among other things on account of the alarm system as described in more detail in section
2.3.7.2. The combined effect was to reduce the capacity for checking for nonconformities
and weak signals of unexpected events.

The AIBN cannot see that the Navy has conducted risk assessments of or had enough
focus in its procedures and guidelines on how training activity on the bridge affects the
functioning of the bridge team. For example, there is no description of or expressly stated
requirement for compensatory measures to be put in place while such training is in
progress, nor any requirement for risk assessments to be approved by the CO when
planning such activity. There is also no specification of competence or what should be
required of instructors. Generally, this becomes particularly critical when such training
activity takes place in combination with navigators who have a low level of experience.
In the present case, the training of two persons probably caused a shift in the bridge
team’s attention and affected their performance of primary and secondary tasks.

2.3.3.4 Level of experience, career path and crewing needs

It emerged from the AIBN’s interviews with representatives of the Navy’s navigational
competence environments that, based on a professional assessment, a cleared OOW
should have completed 2–4 years’ of sea duty, depending on experience, before being put
in charge of training other navigators, and should only be considered an experienced
OOW after 3–4 years’ experience. The investigation indicates that this level of
experience is seldom attained by OOWs on frigates.

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The position of navigation officer is a recruitment position for following a career path on
board Fridtjof Nansen-class frigates. In the case of operative personnel on frigates, it is a
natural career goal to advance to the top position in the operations room and then become
CO. Navigator education and sea practice as OOW on the bridge are necessary in order to
gain a good understanding of safe navigation of the vessel. Younger officers therefore
spend more time working bridge watches than more experienced officers, who spend
more time in the operations room. As a consequence of this, OOWs on frigates generally
have a low level of experience and stand a relatively short time in the position, which
means that responsibility for training is assigned to OOWs with limited experience.

The investigation has shown that the relieving OOW was cleared as OOW after nine
months’ training, which was sooner than what is normally the case for navigation
officers. After four months of being cleared as OOW, the OOW was also assigned
responsibility for voyage planning and for taking charge of navigation training on board,
in addition to working sea watches on the 04–08 watch.

The low level of experience of the OOWs in general and the extensive training that was
being conducted on the bridge are also based on the Navy’s shortage of qualified labour
and the need for new personnel to man the frigates. The following was found, among
other things, in DNV’ survey of the safety culture (see section 1.15.6): ‘One challenge is
therefore that there seems to be an increasing tendency to clear personnel sooner than
used to be the case’. This is mentioned in particular with respect to navigators.

Despite the frigates being manned in accordance with the lean manning concept (LMC,
see section 0), until the reorganisation in autumn 2016, the frigate branch was only able
to operate three of five frigates concurrently because of personnel budget constraints. The
reorganisation entailed transferring many land-based functions to operative functions on
board the Armed Forces’ vessels. Hence, it gradually became possible to operate four of
five frigates concurrently from mid-2017. The Armed Forces have described that the
level of competence and experience is a critical factor for the multi-functionality and
marginal crewing that LMC entails. In the AIBN’s view, the competence and experience
which the bridge team on HNoMS Helge Ingstad had, did not enable the team members
to mitigate the dynamic context in which they were operating this night.

Based on the above, the AIBN believes that the Navy’s need for having more frigates in
operation, combined with the LMC crewing, without having sufficiently considered the
level of competence and experience of personnel, contributed to the accident. As a
consequence of the career ladder for fleet officers in the Navy and the shortage of
qualified navigators to man the frigates, officers of the watch are granted clearance
sooner and with a lower level of experience than used to be the case.
2.3.3.5 Quality assurance of competence

Navigators on frigates have good navigational competence on having completed their

education at the Naval Academy. They acquire this through theoretical learning,
combined with simulator training and extensive practical training on board the Navy’s
school ships. It is a condition for acquiring sufficient fairway knowledge on the path to
obtaining clearance as officer of the watch that the vessel on which they serve offers them
varied training in different areas along the coast.

Practice on board the frigates has been for the CO to grant clearance as officer of the
watch when the candidate has convinced and earned the CO’s trust as necessary, without

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involving the rest of the operating organisation. The OOW’s role as instructor for the
OOWT was also not defined or linked to formal competence requirements. Hence, it was
not ensured that the person charged with training new navigators had sufficient
competence and experience for taking on such a role.

The relieving OOW had received OOW training for nine months before obtaining
clearance, and then served as a cleared OOW for eight months. However, leave of
absence, holidays and periods alongside meant that little time had actually been spent at
sea during that period. Compared with this, a civilian navigator who will navigate a
vessel of corresponding size in the same area has to pass a PEC exam to convince a local
pilot that s/he is familiar with the fairway and the challenges it presents (ref. section
1.13.4.3). In the AIBN’s opinion, the Navy had assigned the OOW a role as instructor
that the OOW did not have a sufficient level of competence and experience to fill. This
relates in particular to responsibility for the ongoing training of two people on the bridge
while also being responsible for safe navigation.

In the Navy, the function of OOWA is not based on any documented training path. Any
able seaman apprentice with a user course in ECDIS can start a course of training as an
OOWAT, without any formal or specific requirements being defined with respect to the
competence that an OOWA must finally possess to fulfil the OOWA’s primary and
secondary duties as described in the bridge manual. In connection with the accident being
considered here, the OOWA could have constituted an important safety barrier in the
sequence of events through operating important bridge systems and assisting the
OOW/OOWT. It appears that the OOWA had not received sufficient training and did not
have the requisite competence to fill this function while at the same time administering
training to the OOWAT.

Given the absence of specific competence requirements, it is difficult to document that

candidates have received correct and adequate training. Clearance without involvement of
the operating organisation, opens up for granting clearance based on a subjective
perception of trust and competence. In combination with press to achieve and deliver
operative capacity this can lead to clearance being granted faster and with less experience
and competence than desired.

The AIBN issues two safety recommendations to the Navy concerning training,
competence and experience level.

2.3.4 The bridge team’s situational awareness at team level

2.3.4.1 Introduction

This section addresses the bridge team’s situational awareness at team level and
functioning compared with what would have constituted optimum teamwork and bridge
resource management (BRM). Cultural aspects that may have affected the functioning of
the bridge team are also discussed.

2.3.4.2 Situational awareness at team level and BRM

Situational awareness at the individual and team level are linked. If a team member
perceives new information about the surroundings and communicates it to the rest of the
team, situational awareness is also developed at team level (Salas et al., 1995).
Information sharing also works as a control mechanism. By the team members sharing or

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coordinating their individual understanding of the situation, it is possible to make

corrections to the team’s situational awareness.

It is not a goal that all members of the bridge team on the frigates shall have the same
detailed situational awareness. According to the procedures, information shall be passed
on from the lookouts and the OOWA to the OOW. It is the navigation officer who shall
consider the information from lookouts and assistants, own observations, information
obtained from charts, radar, VHF etc. together, and compile it to get a correct
understanding of the situation the frigate finds itself in.

In principle, the bridge team on HNoMS Helge Ingstad had clearly defined roles and
responsibilities related to their tasks. The OOW is responsible for conveying a clear and
authoritative picture of the situation. When the OOW has reached a decision and wants to
implement it, orders are issued to the helmsman and assistants, and if applicable to the
lookouts, stating who must do what. This is reflected in the interviews with conscripts in
the bridge team in statements like ‘I do what the officer of the watch tells me to do’, ‘I
don’t keep track of it, as it’s not my job’, ‘I don’t have the competence that the officers
have’, etc.

These internal differences in the bridge team and consideration of competence, time at
sea, duties and responsibility, can easily become factors that impede communication and
teamwork. A more homogeneous and coordinated bridge team would have been more
likely to detect the tanker at an earlier time. More information sharing could also have
made it easier for the HM to realise that the other members of the bridge team had not
understood that the ‘object’ giving off light was a vessel on collision course. On board
HNoMS Helge Ingstad, it was left to the OOW to realise this and take corrective action,
as the other members of the team were not experienced enough to undertake such
deliberations.

Achieving good teamwork (BRM) is particularly challenging in the case of bridge teams
whose members are constantly being replaced. Each member of the bridge team had been
trained on board HNoMS Helge Ingstad, and some had also attended FOST in 2017 (see
section 1.9.7.4). Naval officers and able seaman apprentices have completed courses and
training in BRM as part of their STCW training. According to the Navy, it is highly
probable that individual members of the bridge team on ‘HNoMS Helge Ingstad’ had
been assessed with respect to BMR and teamwork while serving on board, but it cannot
be documented whether such an assessment had been carried out of the practical
teamwork of the bridge team in question.

The Navy has established a navigator project (Prosjekt Navigatøren; see Appendix H) to
strengthen navigation skills. It is pointed out that the ability for effective collaboration in
the bridge teams is given importance in this work, including the implementation of a
more systematic training in Crew Resource Management. The AIBN issues a safety
recommendation supporting this.

The conclusion from the safety review in November 2016 was that, overall, HNoMS
Helge Ingstad had a satisfactory level of sea training (see section 1.9.7.3). The
observations relating to navigation had several features in common, however, with the
findings made in the investigation of the accident considered here. This suggests that the
improvement process may have been inadequate compared to what should be expected
over a two-year period. The Navy has informed the AIBN that it is up to the CO on each

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individual vessel to follow up the recommendations from the safety review. Such follow-
up will, in turn, depend on prioritisation of time, availability and interests on board each
individual vessel. The Navy’s navigator project should also look more closely at whether
the system for following up safety reviews works so that improvement measures are
initiated and implemented.

2.3.4.3 Cultural aspects

It is apparent from interviews that the crew on HNoMS Helge Ingstad had a high degree
of confidence in each other’s skills.

The AIBN’s findings are in line with the findings made by DNV GL in its survey of the
Navy’s safety culture (see section 1.15.6), where the following was documented, among
other things:

- The culture is characterised by mutual confidence and trust in each other’s

knowledge, skills and ability to carry out the job in a good and safe manner.

- The culture is characterised by a fundamental assumption of being in ‘full control’.

According to DNV GL, this can result in lack of necessary cooperation and
involvement during operations. It entails that individuals will tend to be overconfident
in others doing everything right, which is hardly realistic.

- DNV GL also found that many were of the view that ‘safety is maintained through
procedures and good preparedness’, and points to the risk that this entails of
neglecting ordinary/known risks.

As part of the crew on HNoMS Helge Ingstad, the bridge team was a part of the same
culture. In the AIBN’s view, the bridge team’s perception of being in control of the
situation may have contributed to them lowering their shoulders too much and becoming
less alert and sensitive to weak signals of danger (see Appendix G). In the case of the
OOW, it may have resulted in less use of the radar to ensure navigational safety.

2.3.5 Fatigue and functional capacity

2.3.5.1 Assessment of the bridge team

In the investigation, the AIBN has obtained information about the bridge team working
three different watches (4 hours on/8 hours off, 3 hours on/9 hours off, 6 hours on/6 hours
off), and some information about the individual bridge team members’ hours of rest and
sleep during the final 24 hours before the accident. The AIBN has used that information
as well as research on sleep and functional capacity to assess whether the bridge team’s
functional capacity may have been influenced by fatigue.

The interviews with the crew suggest that the exercise they had just completed had not
been particularly hectic or tiring, and exhaustion has therefore not been investigated
further. On the other hand, the AIBN has considered certain aspects relating to fatigue
and the need for sleep.

On the basis of the gathered information concerning sleep and rest, the AIBN considers
that the OOW and OOWA may have been somewhat affected by fatigue, particularly
considering the time of day (according to the circadian rhythm, fatigue is most prominent

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in the early hours of the morning) when the accident occurred. The AIBN considers that
the rest of the bridge team may also to some degree have been affected by fatigue. This
may have affected the functional capacity in important areas such as problem solving and
flexibility of thought, for example in the form of reduced ability to challenge and, if
applicable, adjust the original situational awareness (see Appendix B).

Research has shown that the negative effects of fatigue (see Appendix B) can be difficult
to detect for those who suffer from sleep deprivation. None of the bridge team members
told the AIBN that fatigue was a problem at the time of the accident, though one member
stated not being ‘as up to the mark’ after two weeks of working sea watches as when
being ashore.

In the absence of systematic logging of working hours and hours of rest etc., it has not
been possible to further investigate the degree to which the bridge team may have been
affected. There are also individual differences in how well people are able to function
despite sleep deprivation and fatigue. Hence the AIBN cannot, based on the facts of the
case, be more accurate in its estimation of the effect of this factor on the sequence of
events.

2.3.5.2 Follow-up and control of hours of rest

The procedure for hours of rest and restitution in the Fleet (see section 1.11.8.2) clarifies
responsibility and guidelines. According to the procedure, ‘Those who experience sleep
deprivation have a special responsibility for notifying their superiors’, and ‘The CO is
responsible for ensuring safe operation of the vessel. This means that the CO must
continually assess the risk associated with inadequate rest, and take action when the risk
becomes excessive.’
LMC entails a form of optimisation whereby many positions cover several functions and
are assigned additional tasks. The Fridtjof Nansen-class frigates are built for this concept
and manned accordingly. According to the Armed Forces, this multi-functionality ‘entails
a high workload and requires effort’, and ‘This can mean that individuals may be pushed
to the limits of their capabilities’ (ref. section 0).

In the AIBN’s opinion, it should not be up to each individual to assess the impact of sleep
deprivation on safety-critical functions. In the absence of a system of registration, the CO
has no real possibility of keeping an overview of the crew’s hours of rest, except insofar
as individual crew members report feeling deprived of sleep or it is observed by the CO.
Research has shown that sleepiness impairs the capacity for self-assessment and that
individuals will tend to overestimate their own fitness (see Appendix B). In addition,
LMC also puts pressure on the crew’s capabilities and work performance, which may in
turn lead to further under-reporting.
The Ministry of Defence has initiated the process of establishing protective provisions for
sea-going personnel in the Navy. The regulatory framework is not fully drafted at the
time of publishing this report, but the work so far shows that the Navy’s vessels need
permission from the Ministry of Defence to use fewer hours of rest per day than what is
provided for in Section 24 of the Ship Safety and Security Act.
The AIBN understands the Navy’s needs by virtue of the special nature of its activities,
but calls for a requirement for compensatory measures to be put in place when activities
don`t comply with the framework provided for in the civilian protective provision (at
least 10 hours of rest during every 24-hour period). To achieve a greater understanding

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and acceptance in the Navy of the need for provisions on hours of rest, a system should
be introduced, particularly relating to critical functions, to give the Navy a systematic
overview and positive control of hours of rest.
Based on this, the AIBN issues a safety recommendation to the Ministry of Defence.

2.3.6 Reduced visual function

The Department of Occupational Medicine has performed vision tests of the involved
bridge personnel (see section 1.14.2). The specialist report concludes that it is not
possible based on the results from the vision tests alone to say anything specific about the
degree to which reduced visual qualities of the bridge personnel can be considered a
contributing factor to the accident. The consequences of reduced visual function must be
considered concerning the task each member of the bridge team was to fill, and to how
work on the bridge was organised.

Based on the investigation the AIBN cannot exclude that reduced visual quality for the
bridge team members has influenced on the accident. The AIBN is however of the
opinion that other factors, for example little use of the radar and AIS to monitor the
fairway, was of much greater importance for the accident.

The tests showed that two members of the bridge team, who were performing a duty
when the accident happened in which good visual function was necessary to perform the
persons’ primary tasks, had reduced contrast sensitivity. According to the Department of
Occupational Medicine, one must assume the two individuals in question was
functionally impaired in the situation that arose compared with personnel without such
reduced contrast sensitivity. However, the findings regarding reduced contrast sensitivity
must be interpreted with some caution, as there is some uncertainty related to the
measurement method and threshold values.

In the AIBN’s opinion, contrast sensitivity as a possible medical criterion in the selection
and follow-up of civil and military bridge crews in the future is an important issue, with
the potential for improving maritime safety. However, the possible implementation of
introducing contrast sensitivity as a criterion on a general basis seems to depend on
further research and development in the field.

Two other members of the bridge team did not meet the formal requirements for keeping
bridge watch. Still, but they had sufficient visual function so that the duties they carried
out during the period in question did probably not suffer.

The findings relating to the four members of the bridge team are, however, all relevant
concerning the adequacy of the Navy’s barriers against medical factors causing incidents
and accidents. Medical selection and follow-up is meant to ensure that everybody who
serves in a given position, for example as bridge crew on a frigate, are medically fit to
perform such service safely and effectively. Naval navigation is traditionally more
challenging than ordinary civil navigation as a result of operational requirements that
apply to the vessel and crew. That is why stricter visual requirements apply to personnel
on naval ships than those reflected in the civil regulations.

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The bridge team members were less capable of optical navigation in the dark than they
and the Navy were aware. As a consequence, the bridge team was not correct composed
with regards to meet the requirements for eyesight in current regulations, see Appendix
D. This gives reason to question whether the Navy’s system for medical selection and
follow-up is satisfactory.

Based on this, the AIBN issues a safety recommendation to the Navy to review and
improve its system for medical selection and follow-up with regards to vision.

2.3.7 The frigate’s navigation aids and bridge design

2.3.7.1 Introduction

This section addresses technical factors on the frigate that may have affected the bridge
team’s functional abilities. It starts with a discussion of the frigate’s alarm systems and
possible limitations of the navigation aids used by HNoMS Helge Ingstad on the voyage.
Finally, it discusses bridge design and the position of the radio equipment.

2.3.7.2 The alarm system

The bridge system’s two warning functions (automatic tracking and warning of sleeping
AIS targets; see section 1.9.3.12) that did not require advance detection and tracking by
an operator were normally deactivated in inshore waters. This was because they would
involve automatic tracking of a large number of targets, and many pointless and
distracting alarms that would put excessive strain on the user.

The AIBN has assessed the relevant voyage route from Florø and through the Hjeltefjord
with regards to the use of automatic tracking on AIS. The function could have been an
additional barrier, but probably not without an operator directing much attention to the
system, regularly monitoring and adjusting alarm settings, and acknowledging
unnecessary alarms. The AIBN is of the opinion that the bridge crew would have been
better equipped to avoid the collision by directing their attention to, for example, more
active use of radar and AIS on the relevant voyage route, and have therefore not analyzed
this issue further.

In addition, since neither the OOW nor the OOWA was tracking the ‘object’ on their
respective radar displays, the bridge system did not issue any alarms to indicate that they
were on collision course with Sola TS. The OOW may have chosen not to track the
stationary ‘object’ at the Sture Terminal, since it would have generated pointless alarms
relating to something that did not entail any danger to the frigate’s safe passage.

As described in section 1.9.3.11, a single vessel being tracked on MFD 1, MDF 2 and
MDF 3 will give a total of six alarms. The OOW and OOWA on HNoMS Helge Ingstad
were tracking four vessels during the period from 03:47 to 04:01, which generated a total
of 12 alarms. The alarms were presented with lights and red symbols on the display.
Because the alarms are also audio alarms, they compete with other sound information, for
example communication on the bridge, VHF radio communication etc. According to the
bridge manual, all alarms shall be expressly acknowledged on the bridge to ensure
information flow as necessary.

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According to accepted definitions, alarm systems are meant to draw the operator’s
attention to conditions that require action,46 the point being to transfer and focus the
user’s attention on the cause of the alarm. In this case the alarms probably shifted the
OOW’s attention to the meeting situation with the vessels approaching to port – vessels
that the OOW had already identified and in relation to which the situation was under
control.

Since the tanker was not acquired, no alarms were generated to indicate that HNoMS
Helge Ingstad was on collision course with Sola TS and thereby draw the bridge team’s
attention to this. The OOW focused on being in control of the situation with the vessels
approaching to port in the opposite direction and did not see that a vessel (Sola TS) was
outbound from the Sture Terminal on the western side of the fjord.

2.3.7.3 Limitations of the bridge system

On realising that the ‘object’ to starboard was closer than first assumed, the OOW had to
deviate from the planned route. This meant that the OOW had to compare radar, tracking
and chart information. However, the OOW did not have ECDIS immediately available at
all times while the OOWT and the OOWAT used MFD 3 for optical positioning.

According to the bridge manual, checking coast contours against the radar display is a
method that can be used to control navigation with the aid of radar. The bridge system
worked in such a way that, on changing from ECDIS to radar on MFD 1, the coast
contours had to be restored manually by the OOW. This meant that, if the navigator
switched from radar to ECDIS and back to radar, he/she would lose the method used to
verify the vessel’s position. The navigator would also lose any AIS tracking.

The bridge manual also pointed out that the current MFD 1 solution was ‘inexpedient’
and that the OOW should have access to both ECDIS and radar on separate displays, and
it was described that a new licence must be purchased to be able to display ECDIS on the
conning display.

These limitations of the bridge system may have contributed to the OOW not detecting
the collision danger before it was too late to avoid collision.

2.3.7.4 Bridge design and position of the radio equipment

The handset, which was used by the OOW when HNoMS Helge Ingstad received the call
from the pilot on Sola TS on VHF channel 80, was located next to the Integrated Platform
Management System (IPMS) on the starboard side of the bridge console, approximately
1.5 metres from the radar display (MFD 1). This had two unfortunate consequences:

1. The OOW did not have immediate access to a radar display when having to move to
the handset to answer the call. At this point in time, the OOW had not yet identified
or understood that the ‘object’ was in fact a moving vessel. Being in control of the
meeting situation with the three vessels approaching to port, the OOW did not see any
reason to move along the bridge console to be able to consult the radar display at the
same time.

EEMUA Publication 191 Alarm Systems – a guide to design, management and procurement, Third Edition.
46

www.eemua.org

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2. When the OOW spoke with the pilot on Sola TS on the VHF radio, the other
members of the bridge team did not register what exactly was being said. Only the
HM assumed that it was the vessel to starboard that was calling and asking the frigate
to change course. During an inspection of the sister vessel HNoMS Thor Heyerdahl,
the AIBN registered that messages over the loudspeakers were audible, while what
was being said by the OOW/internally on the bridge was more difficult to catch. It is
an important principle of good BRM that communication/information on the bridge
shall be understood by everybody.

The AIBN has been informed that, on two of the other frigates (HNoMS Roald
Amundsen and HNoMS Otto Sverdrup), the handset had been moved closer to MFD 1
and that there were plans to do the same on HNoMS Helge Ingstad.

The bridge design also meant the individual members of the bridge team were relatively
statically positioned next to each other along most of the width of the bridge (approx. 16
m). All communication thus had to take place sideways, and communication may have
been somewhat impeded by this. The AIBN is also aware that low-frequency fan noise
can pose certain challenges for verbal communication on the bridge, for example between
the OOW and the lookout.

The aforementioned characteristics of the bridge design may have been a hindrance to
obtaining and sharing information in the bridge team, and may thus to some extent have
reduced the possibility of developing a good, shared situational awareness on the bridge.

2.3.8 Organisation, voyage planning and governing documentation

2.3.8.1 Introduction

This section addresses structural factors that may have affected the bridge team’s
functional abilities. It starts with a discussion of the organisation of the bridge team. Then
voyage planning and risk assessments is addressed. Finally, the bridge manual and the
guidelines for the bridge team are discussed.

2.3.8.2 Organisation of the bridge team

The fact that, as chance would have it, the watch changes between the OOWs and
OOWAs, the night meal and the rotation of positions between the bridge crew team took
place at the same time as Sola TS was leaving the Sture Terminal, may have increased the
likelihood that important information and observations were not registered. It may to
some extent have obstructed the development of a common situational awareness (see
Appendix G). That all this took place at the same time as the OOWT, OOWAT and
OOWA were engaged in optical positioning leads the AIBN to conclude that the
organisation of the bridge team was not expedient.

In principle, a watch change can help to improve situational awareness in that the person
being relieved must review the status together with the relieving person, and through a
‘well-rested’ person arriving on the bridge. Furthermore, job rotation is important to
break the monotony of some jobs, which could otherwise lead to poorer concentration. In
the present case, the bridge team did not succeed in detecting that Sola TS was leaving
the Sture Terminal, while the watch changes and job rotation were in progress. Based on
the interviews conducted, it did not emerge that the OOW expressed any clear
expectation that the bridge team was to cover both primary tasks of optical positioning

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and traffic monitoring, despite the ongoing training of two trainees and with only one
lookout.

In the AIBN’s opinion, factors relating to leadership, organisation and teamwork on the
bridge contributed to the tanker not being detected in time to avoid the collision.

2.3.8.3 Voyage planning and risk assessments

The planning of the voyage was based on a standard route. In the AIBN’s view, the
choice of route through the Hjeltefjord follows what is normal for southbound voyages
through this area, with sufficient (700 m) distance to the safety zone around the Sture
Terminal. The route contained comments, but no ‘critical points’ concerning the possible
presence of tankers approaching or leaving the oil terminal or any other dangers it was
important to be aware of along the route.

The frigate sailed south through the Hjeltefjord at a transit speed of 17 knots, which, in
the AIBN’s view, is not uncommon when visibility is good and control is maintained of
other vessel traffic.

The fact that the Navy frequently sails in this area does not mean that all navigators have
the same knowledge or experience of traffic to and from the Sture and Mongstad
terminals. The use of ‘critical points’ in the planning stage can help to increase awareness
of dangers, such as other traffic, along the route.

A notation on the electronic chart concerning the potential presence of tankers

approaching or leaving the oil terminal would provide valuable information, especially
for less experienced navigators, which could be used in the planning and execution of the
voyage through the VTS area. On this specific voyage, this might have provided
information that could have contributed to correcting the OOW’s understanding of what
the ‘object’ was. It should also be natural, especially when navigation training is to be
carried out, to conduct a joint fairway review prior to the voyage.

The AIBN cannot see that governing documentation for the bridge service focuses to any
great extent on risk assessments of the voyage in the route planning.

2.3.8.4 The bridge manual

The bridge manual described that the radar must be used in conditions of poor optical
visibility. The manual made no particular mention of nocturnal voyages, however, which
can be seen as a grey area between navigation in daylight and in conditions of poor
visibility, or in connection with training activity.

The bridge manual described specific methods for checking the vessel’s position, but not
what methods to use for detecting other vessels. It was thus left to the judgement of the
OOW to combine the use of optical principles, radar, ARPA and AIS. The bridge manual
described AIS as an aid to navigation, but said nothing specific about how AIS was to be
used to ensure navigational safety. It did not describe any settings for warning of AIS
targets.

Furthermore, the bridge manual did not mention that vessels must be tracked to generate
an alarm. It neither mentioned the possibility of automatic tracking and defining criteria
for automatic alarm indication of radar and AIS targets, nor the option of setting the

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system to give alarm indication of sleeping AIS targets. The bridge manual did not
describe what method should be used for detection of vessels and tracking, or whether the
preferred method of tracking should be radar or AIS.

Nor was the bridge manual updated with respect to the fact that the function of OOWA
was no longer carried out by navigators in training. The bridge manual referred to the
OOWA as navigator, and referred to the primary and secondary tasks of the OOWA as
requiring a certain level of navigation skills, but the person in question would lack both
the education and experience required of a navigator. The requirement set out in the
bridge manual for one navigator to look out at all times (see section 1.11.7.4) was
unrealistic, as there are situations in which the navigator(s) must consult the chart, for
example to identify objects for taking optical bearings. Furthermore, the instructions for
the lookouts did not mention the use of binoculars.

The bridge manual failed to make clear how the OOW was to quality assure that all
important bridge team tasks were covered when personnel were being trained on the
bridge.

Overall, the AIBN’s review of the bridge manual showed that the manual provided
insufficient job support for the navigator and the rest of the bridge crew with respect to
ensuring a safe passage. This may have contributed to sub-optimal use of the bridge
system, and to the fact that nobody in the bridge team detected the collision danger before
it was too late to avoid it.

The AIBN issues a safety recommendation to the Navy related to the governing bridge
service documents.

2.3.9 The Navy’s use of AIS in connection with inshore navigation

HNoMS Helge Ingstad sailed south through the Hjeltefjord with AIS in passive mode. In
practice, this means that no information was transmitted about the vessel’s identity or
movements in the form of course/speed factors.

The consequence of not using AIS transmission is that information about the vessel is not
made automatically available to other vessels in the area equipped with AIS. Nor will
vessel identity and movement data be automatically displayed on the VTS operator’s
screens. In the same way as navigators on other vessels in the area, the VTS operators
have to use radar to view information about vessel movements, and they must identify
and plot the vessel themselves when necessary.

It was evident from the analysis of the sequence of events that active AIS transmission
could have contributed to Sola TS and HNoMS Helge Ingstad establishing contact before
they did. Such extra time to communicate could have helped to clarify the situation that
was developing.

The AIBN acknowledges the Navy’s special situation compared with other maritime
traffic, in its role as the nation’s power at sea, which entails that it must strike a balance
between different concerns. On the one hand, the Navy will sometimes need to avoid AIS
transmission on account of operational requirements and the need to conceal naval
vessels’ sailing patterns, including in the future. On the other hand, there is a constant
need to exchange AIS data with other vessels for anti-collision purposes in the interest of
safety, particularly in conditions of darkness and poor visibility.

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The investigation indicates that the introduction of AIS and electronic charts has
contributed to establishing a general expectation among seafarers and the VTS centre that
all vessels have a complete overview of the traffic situation. As a consequence of
digitalisation on board ships and increased use of ECDIS and thus also AIS, it has
become generally expected that a vessel’s own navigation system will automatically
display other vessels and information about them. This affects navigation practice and the
relationship between those involved, and, in the AIBN’s opinion, it further adds to the
Navy’s responsibility for the safety of naval and other vessels when electing not to use
AIS transmission on own vessels.

It was a challenge for the maritime safety that the Navy was able to operate without open
AIS transmission and without compensatory safety measures within a traffic system
where the other players largely used AIS as their primary (and to some extent only)
source of information. It was found in the investigation that the Navy had, and still has,
rules for the use of AIS (see section 1.7.2), which have been drawn up for the purpose of
ensuring safety with and without AIS transmission. However, since 2014, the Fleet’s
vessels have generally used AIS in passive mode as a rule rather than by way of
exception. This practice has been established in accordance with the operational
framework plan for the vessels, which, in turn, is based on an increasingly demanding
security policy situation. No established practice, procedures or risk assessments are
available that address the need to be particularly vigilant in connection with the use of
AIS in passive mode.

The Navy’s operational framework plan has led to a practice relating to the use of AIS in
inshore waters that sets aside applicable rules and thereby also the barrier that was
intended to ensure safety. The AIBN is therefore of the opinion that the Navy should
review the relevant regulations and consider all aspects of the Navy’s use of AIS. Since
the need for use of passive or encrypted AIS mode will continue to be present in the time
ahead, compensatory measures must be implemented to ensure the safety of naval and
other vessels.

At the time of the accident, the Navy did not have procedures for the use of W-AIS when
sailing in the Fedje VTS area. The investigation has found that the dialogue between the
NCA and the Navy about the use of W-AIS in the Fedje VTS area, faded away before
guidelines for such use were in place. Procedures for use of the system were not
established between the parties involved, seemingly in part due to a misperception that
the VTS centre did not have the correct encryption key. Thus, there has been no particular
reason for Navy vessels to select mode 3 AIS in the Hjeltefjord, even if some military
vessels may have done it for other reasons.

The investigation has found that if the frigate had set AIS to mode 3 for the voyage, it’s
highly likely that the VTS monitoring system would have displayed the AIS information.
The AIBN considers use of W-AIS in VTS areas to potentially be a valuable safety
barrier in situations where use of AIS mode 1 is not appropriate. The Navy and the NCA
should resume and formalise their cooperation to develop and implement guidelines for
such use, including establishing an arena for exchange of experience and safety learning.

The use of mode 3 will not broadcast AIS information to other vessels in the area, and
compensatory measures for not sailing in mode 1, will still be required. One such
measure could be to inform the VTS centre that the vessel is using mode 3, allowing the
traffic controller to take this into account.

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The AIBN issues two safety recommendations to the Navy concerning use of AIS, one of
which concerns the use of W-AIS in collaboration with the NCA. In addition the AIBN
issues a safety recommendation for the Navy to review their own operating concept and
ensure that safety management and operational needs are compared as management
parameters.

2.3.10 Assessment of measures taken by the Navy

The AIBN has received information about measures initiated by the Navy after the
accident (see 1.17.1 and Appendix H). The Navy has chosen to focus on safety culture,
navigation, technical safety, documentation, competence management and handling of
nonconformities, as well as teamwork training, medical requirements and fitness. The
AIBN considers these areas to be relevant in relation to the safety problems identified in
this investigation.

2.4 The tanker Sola TS with the pilot and the shipping company Tsakos Columbia
Shipmanagement S.A.

2.4.1 Introduction

The following topics are discussed in this section on Sola TS, the tanker’s pilot and the
shipping company Tsakos Columbia Shipmanagement (TCM) S.A.: Cooperation between
the pilot and bridge team, use of deck lights, use of available warning aids and VHF
communication between Sola TS and HNoMS Helge Ingstad.

Our assessment is based on the sequence of events, interviews with the bridge personnel,
the shipping company’s navigation procedures manual and the tanker’s navigational aids,
among other things.

2.4.2 Cooperation between the pilot and the bridge team

The bridge team and the pilot on Sola TS experienced good control of the voyage and the
other ship traffic in the area. The radar provided true trails which gave a good indication
of speed and heading of the other vessels (see Figure 10). The crew explained that they
therefore did not consider it necessary to plot the vessels on Sola TS’ radar. Nevertheless,
the AIBN finds that there are areas of improvement also concerning Sola TS’ practice,
especially with regards to the cooperation between the pilot and the bridge crew.

The shipping company’s navigation procedures manual describes how the bridge crew is
organised as a team so as to safeguard against and correct possible errors. Even if not
recognised as part of the watch team, the pilot plays an important role on the bridge, and
it is the responsibility of the bridge team to include the pilot in the team. The NCA’s
pilotage instructions also point out that the pilot shall make efforts to establish good
BRM and take active part in the vessel’s bridge team.

While sailing north towards Fedjeosen, communication between the pilot and the rest of
the bridge team was limited to trivial matters. There was little communication about the
voyage and about the other vessels that were approaching.

The navigation procedures manual also points out that English should always be
established as the common communication language between the pilot and the bridge
team, and that English shall be used for all internal and external exchange of information

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about the vessel’s operations. For this particular departure, the master and pilot had
agreed that the pilot could speak Norwegian on the VHF radio when communicating with
Fedje VTS and the tugboats. Norwegian was also used in the subsequent communication
between the pilot on Sola TS and the bridge watch team on HNoMS Helge Ingstad. The
pilot retold what the pilot considered relevant information to the master on Sola TS. It
was not found in the investigation that any essential information was lost as a
consequence of this, but the AIBN is of the opinion that this type of practice can entail
that the bridge team lose out on the possibility of understanding the situation and of
intervening, if applicable, at an earlier point in time.

The first mention of HNoMS Helge Ingstad was when the pilot (at 03:57:25) asked the
master if there was any information about the vessel that was approaching from the north.
That was just under four minutes before the collision was a fact.

The master and the pilot on Sola TS had experience of taking tankers out from the Sture
Terminal. The tanker was also sailing within the Fedje VTS area. In addition, the master
and pilot had good visual control over all the traffic in the area. This can explain why
those manning the bridge on Sola TS did not consider it necessary to exchange much
information. The AIBN’s general opinion is that not establishing communication about
vessel traffic on the bridge may increase the threshold for notifying of any uncertainty.

According to the bridge procedures manual, the navigating officer shall, among other
things, operate the radar/ARPA and other navigational equipment, and plot all targets
within a range as decided by the master. It was pointed out in the relevant passage plan
that there was a high danger of collision on account of there being much traffic in the area
they were passing through after leaving the Sture Terminal. However, the investigation
has shown that none of the other vessels in the Hjeltefjord the night of the accident were
plotted on any of the tanker’s radars. This indicates that the crew on Sola TS found it
natural to use AIS information on the ECDIS display as their source of information about
other maritime traffic. It is also the AIBN’s opinion that the lack of plotting may indicate
that the bridge team took a less active role with the pilot on the bridge.

By letting the pilot play the most active role on the tanker’s bridge, while the bridge team
assumed a more standby role, the corrective effect of active teamwork to build up a
common situational awareness can be reduced; see Appendix G. This is to some extent in
line with findings from previous investigations of accidents involving vessels under
pilotage47. The AIBN has previously issued a safety recommendation48 on this subject to
the Norwegian Coastal Administration.

The AIBN issues a safety recommendation to the shipping company in order to review
and revise practice for bridge teamwork and safe navigation with pilot on board.

2.4.3 Use of deck lights

Sola TS left the quay with the forward-pointing deck lights on. The AIBN’s experience
on the observation voyage showed that it was difficult, even through binoculars, to
discern the tanker’s navigation lights from the deck lighting (see Figure 52). This implies
that it cannot have been easy for the bridge crew on HNoMS Helge Ingstad to observe the

47
Ref. AIBN reports Report Marine 2010/01 and Report Marine 2010/04, among others.
48
Safety Recommendation Marine no 2010/04T in Report Marine 2010/01.

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navigation lights on Sola TS. As a consequence of the deck lights it was visually
challenging for the bridge crew on the frigate to identify the tanker as a vessel.

Figure 52: Photos from the observation voyage taken at a time corresponding to approximately
03:55 the night of the accident. On the left: the view from the bridge on Sola TS, with HNoMS
Roald Amundsen marked with a white circle. The photo on the right shows what Sola TS may
have looked like from the bridge on HNoMS Helge Ingstad. The distance between the vessels
was approximately 2.3 nm at the time. Photo: The police/the shipping company/AIBN

As described in section 1.12.3, the company had established procedures relating to the
safety of the crew while working on deck. However, the company had not established
compensatory safety measures with regards to the reduction of the visibility of the
navigation lights due to deck lighting.

It is a known fact and normal practice that the tankers on their way to the terminal need to
start preparing for mooring and loading, and that the vessels on their way out prepare for
the ocean-going voyage. The use of deck lights during mooring operations is according to
what the shipping company considered best practice. To work safely on deck while
securing for sea, the deck crew depends on good lighting.

The AIBN sees the company’s need to safeguard the working environment, but at the
same time the use of deck lighting must not be at the expense of maritime safety. The
AIBN issues a safety recommendation to the shipping company to establish measures for
the use of deck lighting, which ensures that the lighting does not conflict with the
visibility of navigation lights.

The AIBN does not have an overview of other cases where the deck lighting has reduced
the visibility of the vessel’s navigation lights, but to the extent that the visibility of the
navigation lights is reduced this may pose a risk. The AIBN issues a safety
recommendation to the Norwegian Maritime Authority to address the industry in general
in this regard.

2.4.4 Use of available warning aids

Sola TS did not have access to AIS information about HNoMS Helge Ingstad. When the
need arose to establish contact with the vessel, the pilot called Fedje VTS. Fedje VTS did
not know the identity of the vessel either. The pilot did not attempt to make a call for
example directed to all ‘southbound vessels just north of the Sture terminal, which the
AIBN believes would have been a good option. The frigate was not plotted on the radar

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on Sola TS, whereby more specific information could have been provided about the
frigate’s course and speed had such a call been made.

The pilot considered other options for establishing contact with the vessel. At 03:59:02,
the pilot asked the master on Sola TS to use the Aldis lamp to send out signals to the
vessel and get her attention. Given the view that the bridge team on Sola TS had of
HNoMS Helge Ingstad (see Figure 52), the AIBN can understand the assumption that the
flashes from the Aldis lamp would be observed by the approaching vessel.

Experience on the observation voyage showed that the flashes from the Aldis lamp could
only just be discerned between the yellow lights without using binoculars. This depended
on looking straight into the deck lights, which the bridge team on HNoMS Helge Ingstad
probably felt was unnatural, as they were focused on maintaining their night vision.

Sola TS did not use sound signals in the attempt to call on the attention of HNoMS Helge
Ingstad. Any attempt by Sola TS to establish contact with ‘HNoMS Helge Ingstad’ by
sounding the fog horn would probably have failed, because the frigate’s lookouts and
other bridge team members were inside the enclosed bridge. On the observation voyage,
the fog horn of Sola TS was audible on the bridge of HNoMS Roald Amundsen when the
door to the bridge deck was open, but not when it was closed49. On the basis that the
personnel on the bridge of Sola TS were convinced that the tanker was highly visible to
the approaching vessel, the AIBN understands why they did not consider using the fog
horn.

The course of events might have been different had the flashes from the Aldis lamp and
the navigation lights not been concealed by the forward-pointing deck lights on Sola TS.
In the AIBN’s opinion the members of the bridge team on Sola TS could not have been
aware of the effect of the deck lights on the visibility of both flashing lights and
navigation lights, and hence, they did not consider turning off the lights to achieve greater
visibility.

2.4.5 VHF radio communication between Sola TS and HNoMS Helge Ingstad

When the pilot on Sola TS was told by the VTS operator that the approaching vessel was
HNoMS Helge Ingstad, the pilot immediately called the frigate. The OOW on HNoMS
Helge Ingstad answered, and the pilot on Sola TS asked: ‘Is that you approaching?’, and
gave the message: ‘You must turn to starboard immediately’. This communication did not
provide the OOW on HNoMS Helge Ingstad with information that enabled the OOW to
change the prevailing situational awareness.

Had the pilot stressed that it was the tanker Sola TS calling, outbound from the Sture
Terminal and on collision course with the HNoMS Helge Ingstad, and asked the frigate to
turn to starboard, the OOW/bridge team on HNoMS Helge Ingstad would probably have
detected the collision danger before they did.

The pilot was probably convinced that HNoMS Helge Ingstad observed Sola TS both
visually and by AIS and radar. The pilot therefore found it unnecessary to inform
HNoMS Helge Ingstad of their relative positions. The AIBN believes that, with the
introduction of ECDIS and AIS, a general expectation has gained foothold among

49
VSS Sound Reception System intended to capture audio signals in fog or in poor visibility, was not switched on
during the observation voyage and probably not at HNoMS Helge Ingstad on the night of the accident.

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seafarers that all vessels in the vicinity have a complete overview of the traffic situation,
and this also affects how seafarers communicate with each other.

2.4.6 Assessment of measures implemented by the shipping company

The AIBN has received information about the measures implemented by the shipping
company after the accident. The AIBN cannot see that the shipping company has
implemented changes in connection with any of the possible areas of improvement
relating to its vessels that have been identified by this investigation. This concerns use of
deck lights and the shipping company’s own navigation procedures with pilot on board.
The shipping company states that use of deck lights is normal and safe practice, and does
not see that the deck lights can make the navigation lights less visible. The AIBN does
not share this view.

2.5 Fedje VTS and the Norwegian Coastal Administration (NCA)

2.5.1 Introduction

This section addresses the VTS centre’s tasks relating to traffic monitoring, information
service and traffic organisation. Consequences of the choice of language used for
communication between seafarers and the VTS, as well as traffic separation and position
in the fairway, are also discussed in this section.

Our assessment is based on the sequence of events, interviews with the VTS operators,
the VTS centre’s procedures and systems, and information obtained from the NCA’s
Department for Maritime Safety, among other things.

2.5.2 Traffic monitoring

Fedje VTS shall continuously monitor its service area for the purpose of detecting
situations in which there is a danger of collision or grounding. The AIBN considers
traffic monitoring to be of the utmost importance in enabling the VTS centre to carry out
its information, traffic organisation and navigation assistance services. The VTS shall
give special priority to vessels carrying hazardous or noxious cargoes between the oil
terminals and pilot boarding ground, among others.

Lack of monitoring meant that the VTS operator’s situational awareness and overview of
the VTS area were inaccurate. For instance, the VTS operator at Fedje VTS was unable to
identify HNoMS Helge Ingstad immediately on the request from the pilot on Sola TS.
The investigation has shown that HNoMS Helge Ingstad was not plotted on the VTS’s
radar when the frigate notified of entering the VTS area.

According to the NCA the general routine at the VTS centre is that vessels are plotted
when they are within the screen layout on the operator’s main screens (see Figure 40).
This was also normal for the VTS operator who was on duty, but in this case, it was
forgotten.

C-Scope includes functions whereby a zone can be defined for automatic plotting of
vessels without AIS transmission. The system can be set to generate warnings and alarms
on these plots, to draw the VTS operator’s attention to the vessel. According to the NCA
the functionality has been tested locally by the first VTS centre who started utilizing the
system, but since it was not sufficiently adapted to the execution of the vessel traffic

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service the functionality was not chosen. The NCA has in cooperation with the equipment
supplier initiated testing and analysis in order to identify how the automatic plotting,
warning and alarm functions can be improved (see section 1.17.3.2). Furthermore, the
testing of the system has shown that the functionality for ‘dead reckoning’ needs to be
further developed before it can be used operationally. The NCA has informed the AIBN
that a dialogue with the equipment supplier on improvement of this functionality, has
been initiated (see section 1.17.3.3).

Because HNoMS Helge Ingstad did not transmit AIS signals, the monitoring system did
not automatically display the vessel with identity and speed/course vectors. This means
that, in a critical phase of the sequence of events leading up to the collision, the VTS
centre was unable to assist the pilot with information about the approaching vessel. This
further delayed the time at which the pilot on Sola TS established contact with HNoMS
Helge Ingstad.

This was the first night shift worked by the VTS operator after returning from a long free
period, and the operator had not slept since the morning on the preceding day. The AIBN
considers it probable that the time of day (circadian rhythm), and the transition from
staying awake in the day to staying awake at night, may have affected the VTS operator’s
level of attention (see Appendix B), and the number of hours of continuous wakefulness
may have been a contributing factor to HNoMS Helge Ingstad not being plotted and
monitored. Furthermore, the work as a VTS operator entails a lot of screen use and the
job is somewhat repetitive and sedentary, which can cause a gradual weakening of the
ability to concentrate.

It is important that organisations establish human, technical and organisational barriers to

compensate for the risk that follows from human limitations. In the present case, there
were not sufficient barriers in place at the VTS centre. The AIBN considers that the
monitoring system’s functionality should be improved so that it can be utilized by the
VTS centers.

Concerning Warship AIS, discussed in section 2.3.9, today it is not possible on the C-
SOC monitors to see the difference between a W-AIS and a standard AIS. The symbol on
the screen will not tell the traffic controller whether a naval vessel is transmitting AIS in
encrypted or open mode. A traffic controller who is not aware that the system may be
displaying W-AIS, will assume that other vessels in the area are also able to see AIS
information on the naval vessel. This can potentially lead to misunderstandings that affect
safety. It seems reasonable to assume that a technical modification of the system can
address this limitation. At least such a solution is worth pursuing.

There is no specification in the NCA’s procedures/instructions of what sensors to use for

traffic monitoring, other than that the NCA describes AIS as a supplement to radar. As
described before (see section 2.3.9 and 2.4.5), the investigation indicates that the
introduction of AIS and ECDIS has contributed to establishing an expectation that
everybody has a complete overview of the traffic situation. It has also contributed to less
manual radar plotting of vessels on the part of the VTS. In the present case, this
contributed to the frigate being forgotten and thus not monitored while passing through
the area.

The AIBN recommends that the NCA review and improve how traffic monitoring is
conducted.

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2.5.3 Information Service (INS)

Monitoring and adequate situational awareness are basic conditions for the VTS centre’s
ability to operate an efficient and correct information service.

The NCA has drawn up a set of instructions for the VTS operators at Fedje VTS,
describing how and when information shall be provided. The instructions state that the
VTS operators shall provide information services so as to make relevant information
available to vessels in time for navigational decisions to be made on board. Particular
mention is made of informing about vessels leaving their moorings within the VTS area.
Communication of such information by the VTS shall be preceded by the message
marker Information.

The pilot on Sola TS notified Fedje VTS that they were starting to take in the mooring
lines at the Sture Terminal at 03:13. At that time, there was little maritime traffic in the
vicinity of the terminal. The three northbound vessels were 6.5 nm south of the terminal.
HNoMS Helge Ingstad was approximately 14 nm north of the terminal.

Based on the pilot’s message that the tanker was preparing for departure (taking in the
mooring lines) at 03:13, Fedje VTS could not know exactly when the tanker would be
leaving the terminal. The preparations can take a shorter (20 minutes) or longer time (1
hour) as circumstances can arise that delay the departure. Given that there was
uncertainty about the actual time of departure, the AIBN understands why the VTS
operator did not convey the message to other vessels in the area at this point in time.

The AIBN finds that Fedje VTS did not adequately inform other traffic in the area of Sola
TS leaving the Sture Terminal. Other than the conversation between the pilot and the
VTS centre, which took place in Norwegian, the VTS centre did not provide any specific
information to vessels in the area about the tanker that was leaving the Sture Terminal at
03:45. This part of the investigation also indicates that a general impression has formed
among seafarers that AIS and ECDIS entail that everybody has a complete overview of
the traffic situation. In turn, this has given rise to the view that there is less need for the
VTS centre to provide information.

In the AIBN’s opinion, it is important to contribute to making all vessels aware of the
situation when tankers operate within the VTS area. Due to the lack of traffic information
the frigate’s bridge team missed an opportunity to catch that a tanker was leaving the
Sture terminal.

On that basis, the AIBN issues a safety recommendation to the NCA in order to revise the
current practice and routines relating to traffic information. Furthermore, information
from the VTS centre must be communicated in a way that ensures that it can be
understood by all navigators on watch in the relevant area. See also section 2.5.5.

2.5.4 Traffic Organisation Service (TOS)

As mentioned in section 2.5.1, the VTS centre shall monitor the service area continuously
for the purpose of detecting situations that entail a danger of collision or grounding. The
VTS centre shall seek to facilitate that large tankers can complete their planned passage
without being obstructed by other traffic.

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Sola TS notified of her departure at 03:45 and started on the outbound passage towards
Fedjeosen. The VTS operator has stated that, then and there, a lot of resources were spent
on addressing the situation near the Sture Terminal. The VTS operator zoomed in on the
area near the Sture Terminal on the main work screen to check whether Sola TS had
sufficient time and space to manoeuvre in relation to other vessels in the area, and
concluded that this was the case. The three northbound vessels were approximately 2 –
3.5 nm south of the Sture Terminal. HNoMS Helge Ingstad was 5.8 nm north of the Sture
Terminal, and outside the area that the VTS operator had zoomed in on, and was thus not
part of the traffic situation being considered by the VTS operator. Based on the VTS
operator’s situational awareness, the operator decided that there was no need for traffic
organisation or for issuing information to vessels in the area.

Following the departure of Sola TS, the VTS operator’s main work screen remained
zoomed in on the area near the Sture Terminal. In the combination with the lack of radar
plotting, this contributed to the VTS operator not remembering HNoMS Helge Ingstad in
the subsequent sequence of events.

Traffic monitoring is essential in order to provide the VTS centre with the necessary
scope of action for early, effective and safe traffic organisation. The AIBN finds that this
scope of action had largely been lost when the VTS centre once again became aware of
the presence of ‘HNoMS Helge Ingstad’ after receiving the call from the pilot requesting
information about the vessel.

Once Sola TS and HNoMS Helge Ingstad had established contact, the VTS operator felt
that the situation would be resolved. At that point in time, the two vessels were so close
that it was natural that the VTS operator left communication and clarification of the
situation to the two vessels’ bridge teams.

However, a navigator passing through the VTS area would probably perceive a call from
the VTS operator as more authoritative than a call from what the OOW on HNoMS Helge
Ingstad understood to be a navigator on one of the three vessels approaching in the
opposite direction. It is possible that the OOW on HNoMS Helge Ingstad had acted
differently had the OOW received a VHF radio call from the VTS operator and had the
VTS operator used clear message markers and ordered the OOW to turn to starboard or
bring the frigate to an immediate stop.

The VTS operator could not be absolutely certain, however, that the vessel was HNoMS
Helge Ingstad, since there had been no plotting or tracking of the vessel. Furthermore, the
VTS operator did not have the same possibility of making visual observations as the two
vessels involved. The VTS operator probably also assumed that the two vessels were
aware of each other based on both visual observations and radar/AIS information. When
the OOW on HNoMS Helge Ingstad answered that they were unable to turn to starboard,
the VTS operator did not understand why. The VTS operator did not want to intervene in
a situation of which the VTS lacked an overview and did not understand.

2.5.5 Language

The navigation officer on watch and the helmsman on Sola TS, who were both from the
Philippines, remained inside the bridge when the master and pilot went out on the bridge
wing. On the bridge, it was possible to listen in on communication with the VTS as long
as the communication was in English.

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The bridge team on Sola TS did not speak Norwegian, and the OOWT on HNoMS Helge
Ingstad was not fluent in Norwegian. However, the pilot spoke only Norwegian when
communicating by VHF with Fedje VTS, the tugboats and, later on, also with HNoMS
Helge Ingstad. The pilot retold what the pilot considered to be relevant information from
the VTS to the master on Sola TS. It was not found in the investigation that any essential
information was lost.

The OOWT on HNoMS Helge Ingstad did not usually listen actively to the VHF radio,
since the communication was usually in Norwegian. It was the OOW who followed up
the radio communication, but the OOW’s attention was on the watch handover when Sola
TS notified of her departure from the Sture Terminal at 03:45.

The AIBN considers that, as a result of the language barrier, both the captain on Sola TS
and the OOWT on HNoMS Helge Ingstad may have lost out on the possibility of
understanding the situation and taking appropriate action at an earlier point in time. Two
of the northbound vessels approaching to starboard of Sola TS also had English-speaking
navigators who did not understand what was happening prior to the collision.

The VTS operators consider that many others (Norwegian-speaking) would lose out on
the communication if only English was used for VHF radio communication. On being
notified of entry into the VTS area by vessels exceeding 24 m, the VTS operators learn
what languages the various vessels use. For this group of vessels, the VTS operators will
thus be aware of what languages are relevant to use.

In the AIBN’s opinion, the choice of language was in this case unfortunate, but it was not
a factor that contributed to the accident. The AIBN considers it important to safety,
however, that everybody understands what is being communicated on the bridge and by
VHF radio. It should be possible to issue brief safety messages in both English and
Norwegian. According to the NCA they will propose an amendment of the language
provision in connection with the next revision of the Maritime Traffic Regulations (see
section 1.17.3.6).

2.5.6 Traffic separation, positioning in the fairway and use of ECDIS with AIS

The outbound route of Sola TS from the terminal was planned on the tanker’s ECDIS.
During the master-pilot exchange before departure, the passage was discussed by the pilot
and master, who agreed to follow the planned outbound route to the pilot disembarkation
area. According to Fedje VTS’s instructions for traffic organisation, vessels of more than
30,000 GT carrying hazardous or noxious cargo shall use the shortest fairway from
Fedjeosen to/from the Sture Terminal. The planned outbound passage of Sola TS from
the Sture Terminal and through Fedjeosen was in line with normal practice for tankers
calling at the terminal (see Figure 41).

The alternative for Sola TS would have been to head across the fjord a little further and
make a wider turn. This can be a challenge for big tankers. Heading straight towards the
eastern shore of the fjord with a fully loaded tanker while building up speed would not be
the natural course of action for the navigators on board. The pilot on Sola TS considered
it important to turn the bow northwards as soon as possible. This would provide more
open water ahead, which is important for a fully loaded tanker that is difficult to bring to
a stop and that has limited manoeuvring capabilities.

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No traffic separation scheme has been established in the Hjeltefjord. Both Sola TS and
the tree northbound vessels were on the port side of the fairway. The investigation has
also shown that it was normal for vessel traffic in the area (see section 1.13.5) to take the
shortest route when heading north, even if this meant that they were on the port side of
the fairway. The VTS operators have stated that, after the introduction of AIS, vessels
generally operate differently from what they did before. They now take the shortest route
when heading out through the fjord, as opposed to what was previously the case, when
the vessels steered through sectors and to starboard of the middle of the fairway.

The investigation indicates that seafarers have too much confidence in electronic charts
with AIS information providing a complete overview of the traffic situation. This
probably contributed to Fedje VTS and Sola TS making insufficient use of available
technical aids, particularly radar plotting. The AIBN does not have an overview of other
cases where this have been a safety issue. Therefore the AIBN does not have sufficient
basis for issuing a safety recommendation. It could nevertheless be of interest, both for
the Norwegian Maritime Authority and the Norwegian Coastal Administration, to look
closer at how the use of electronic charts with AIS information has affected the
navigation safety in Norwegian waters.

Based on the information available to the AIB, the vessel traffic in the Hjeltefjord has not
been discussed by the VTS operators at Fedje or by their superiors in the NCA. In 2014,
it was concluded in a study by DNV GL, commissioned by the NCA, that safety at sea
would benefit from the introduction of a traffic separation scheme (TSS). The risk-
reducing effect of traffic separation schemes and recommended fairways is also
mentioned in the white paper on preventive maritime safety and preparedness against
acute pollution (Report to the Storting No 35 (2015–2016) På rett kurs).

Based on the AIBN’s assessment, the introduction of traffic separation in the Hjeltefjord
will not necessarily improve maritime safety for the area as a whole. Any introduction of
traffic separation in the fairway must also be considered in relation to what challenges it
can create for traffic entering and leaving other fairways to and from Bergen, and in
relation to whether traffic organisation by Fedje VTS can provide the same degree of
safety.

2.5.7 Assessment of measures implemented by the NCA

The AIBN has received information about measures initiated by the NCA after the
accident. The NCA has identified several areas for improvement, see section 1.17.3. The
AIBN considers these areas to be relevant in relation to the safety problems identified in
this investigation.

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3. CONCLUSION
3.1 Introduction

The AIBN’s investigation has clarified the sequence of events, as well as how and why
the two vessels collided outside an oil terminal in an area monitored by a VTS centre.
The investigation has shown that the situation in the Hjeltefjord was made possible by a
number of operational, technical, organisational and systemic factors.

3.2 The sequence of events, operational and technical factors

During the night leading up to 8 November 2018, HNoMS Helge Ingstad sailed south
from Sognesjøen to the Hjeltefjord at a speed of approximately 17–18 knots with AIS in
passive mode. The frigate’s bridge team had notified Fedje VTS of entering the area and
followed the stated voyage. The passage through the Hjeltefjord was not considered
particularly demanding, as the fairway is open and offers a good view all around. The
VTS operator at Fedje VTS logged HNoMS Helge Ingstad, but did not plot the vessel in
the monitoring system.

Navigation training was being conducted on board HNoMS Helge Ingstad as usual during
a transit voyage. The officer of the watch trainee (OOWT) was navigating the frigate and
was to carry out all tasks normally performed by the officer of the watch (OOW). The
OOW was in charge on the bridge. The OOW, who had not held clearance as officer of
the watch for very long, led a team consisting of young conscripts with limited maritime
experience, at the same time as training was in progress for two watchstanding functions.
During the night in question, the OOWT and the officer of the watch assistant trainee
(OOWAT) were receiving training in optical positioning in particular.

During the same period, the tanker Sola TS was preparing to leave the Sture Terminal.
Sola TS had some of the deck lights turned on to light up the deck for the crew who were
securing equipment etc. for the passage. Sola TS also exhibited navigation lights.

The pilot on Sola TS notified Fedje VTS by VHF radio of departure from the Sture
Terminal at 03:45. The VTS operator acknowledged receipt of the message. The VTS
operator zoomed in on the area near the Sture Terminal on the main work screen to check
whether Sola TS had sufficient time and space to manoeuvre in relation to other vessels.

The three northbound vessels were approximately 2 – 3.5 nm south of the Sture Terminal.
HNoMS Helge Ingstad was 5.8 nm north of the Sture Terminal, and outside the area that
the VTS operator had zoomed in on, and was thus not part of the traffic situation being
considered by the VTS operator. The VTS operator saw no need for traffic organisation
or for issuing information to vessels in the area. Following the departure of Sola TS, the
VTS operator’s main work screen remained zoomed in on the area near the Sture
Terminal. In the combination with the lack of radar plotting, this contributed to the VTS
operator not remembering HNoMS Helge Ingstad in the subsequent sequence of events.

At the same time as Sola TS notified of her departure from the Sture Terminal, the watch
handover between the OOWs started on HNoMS Helge Ingstad, while the OOWT
continued to navigate the frigate. During the watch handover, the OOW being relieved
and the relieving OOW observed an object at the Sture Terminal, to starboard of the
frigate’s course line. The ‘object’ was observed both visually and on the radar display in

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the form of a radar echo and AIS symbol. The two OOWs discussed, but did not clarify,
what the ‘object’ might be. Both OOWs had formed the clear perception that the ‘object’
was stationary near the shore and thus of no risk to the frigate’s safe passage.

Once Sola TS had manoeuvred out from the quay, the tanker set the planned course
towards Fedjeosen and increased the speed to around 6–7 knots. At this point in time,
there was a distance of approximately 4 nm between the vessels.

After the watch handover on HNoMS Helge Ingstad, the relieving OOW’s further
decisions and actions relied on the situational awareness that the ‘object’ at the Sture
Terminal was stationary. The investigation has demonstrated that it was difficult to
rectify this situational awareness based on visual input alone.

As far as the AIBN has found, none of the messages from Sola TS to Fedje VTS over
VHF channel 80 were registered at HNoMS Helge Ingstad. This can be related to the
watch handover between the OOWs, that traffic information was not provided by Fedje
VTS, and how an operator registers and filters the communication that takes place on the
radio.

When Sola TS first started manoeuvring out from the quay, this was done so slowly that
it was difficult to register any movement from the bridge on HNoMS Helge Ingstad. The
lights from the tanker appeared to be an extension of the lights from the terminal. Sola TS
was more clearly away from the terminal when the tanker turned her bow northwards
towards Fedjeosen, so that the forward-pointing yellow deck lights became visible. The
navigation lights on Sola TS were then difficult to discern because of the deck lights. The
tanker appeared to be an object giving off light, and it was difficult to judge the distance
in the dark.

On the bridge of the frigate, the training activity took parts of the bridge team’s attention.
Hence, during the decisive period before the collision, the bridge team had reduced
capacity to monitor the traffic situation. In addition, the starboard lookout position was
unmanned, and this meant that a barrier was weakened during a period when Sola TS
could have been identified as a vessel on collision course.

Furthermore, certain of own situational awareness, the relieving OOW on HNoMS Helge
Ingstad did not see any need to carefully monitor the fairway on the radar. Since the
‘object’ was assumed to be stationary, it was not investigated further or tracked on the
radars on board HNoMS Helge Ingstad. The OOW was focusing on the three vessels
approaching in the opposite direction to port of HNoMS Helge Ingstad, which had been
observed visually and tracked in the bridge system. Since the tanker was not acquired, no
alarms were generated to indicate that HNoMS Helge Ingstad was on collision course
with Sola TS and thereby draw the bridge team’s attention to the collision danger.

The OOW eventually realised that the ‘object’ giving off light on the starboard bow was
closer to the frigate’s course line than first assumed. The OOW has stated that the
‘object’ was primarily observed visually, but the OOW had also seen on the radar that a
little distance had appeared between the shore and the ‘object’. The OOW was still under
the impression that this was a stationary object close to the Sture Terminal, that there was
no room to pass between the ‘object’ and the terminal, and that the distance between the
shore and the ‘object’ on the radar screen could be explained by the frigate having come
closer to the point which the ‘object’ lay alongside.

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A more experienced OOW would probably have had greater capacity to pick up on weak
signals of danger and be better equipped to suspect that his/her own situational awareness
suffered from misconceptions. The OOW thought, however, that the course had to be
adjusted slightly to port to increase the passing distance to the ‘object’. The course was
then adjusted by a total of 10 degrees to port through a series of small course changes.

Neither HNoMS Helge Ingstad nor any other vessels were plotted on the radar on Sola
TS, this may indicate that the bridge team took a less active role with the pilot on the
bridge. Furthermore, there was little communication between the bridge team and the
pilot about the passage and the general traffic situation in the fairway. This meant that the
effect of active teamwork to build a common situational awareness, was not sufficiently
ensured.

A while after setting course towards Fedje, the pilot reacted to the approaching vessel
drawing closer without any indication of giving way. That was approximately four
minutes before the collision, at which point the distance between the vessels was
approximately 1.5 nm. As a consequence of HNoMS Helge Ingstad not transmitting AIS
signals on this voyage, the name of the vessel that was approaching in the opposite
direction was not presented on the displays on Sola TS.

The pilot requested information about the approaching vessel from Fedje VTS. The VTS
operator had not monitored the passage of HNoMS Helge Ingstad after the frigate
notified of entering the area, and was therefore unable to identify the vessel immediately.

The crew on Sola TS tried to establish contact with the vessel by flashing the Aldis lamp.
The flashes from the Aldis lamp were concealed by Sola TS deck lights, and were
therefore not perceived by the bridge team on HNoMS Helge Ingstad. The bridge team
and pilot on Sola TS were probably not aware of the effect of the deck lights on the
visibility of both flashing lights and navigation lights. Sola TS altered course 10 degrees
to starboard, to indicate an evasive manoeuvre to the approaching vessel.

When the pilot on Sola TS was told by the VTS operator at Fedje VTS that the meeting
vessel was HNoMS Helge Ingstad, the pilot immediately called the frigate. A total of 2.5
minutes passed from the time the pilot reacted to the approaching vessel until they got in
contact with HNoMS Helge Ingstad.

At that point in time, the vessels were so close to each other that the VTS centre’s scope
of action had become very limited. Furthermore, the VTS operator did not have the same
possibility of making visual observations as the two vessels involved. The VTS operator
also assumed that the two vessels could see each other on the bridge instruments.
Therefore the VTS operator left the further communication and clarification of the
situation to the two vessels’ bridge teams.

The OOW on HNoMS Helge Ingstad answered the call from the pilot on Sola TS
immediately. The pilot asked HNoMS Helge Ingstad to turn to starboard. The OOW
responded by saying that they were unable to turn to starboard. This was based on the
firm perception that the floodlights came from a stationary object close to shore and not
from a vessel. Furthermore, the OOW assumed that it was one of the three northbound
vessels approaching to port that was requesting the frigate to alter course to starboard, as
the frigate had just adjusted the course to port.

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An avoidance manoeuvre to prevent collision would still have been possible at this point
in time, had a correct decision been made and correct action taken. However, the
communication between the pilot on Sola TS and the OOW on HNoMS Helge Ingstad
did not provide the OOW with information that enabled the OOW to rectify the
situational awareness. The pilot was convinced that HNoMS Helge Ingstad could see
Sola TS both visually and on the bridge instruments.

When HNoMS Helge Ingstad did not alter course, the master on Sola TS ordered ‘stop
engines’ and, shortly afterwards, the pilot ordered full speed astern on the engines. These
two measures were carried out only short time before the collision, and were therefore
without material effect. Any use of the escorting tugboat to change course or bring the
tanker to stop would probably also have been ineffective at this late stage of the sequence
of events.

When the OOW on HNoMS Helge Ingstad understood that the ‘object’ giving off light
was moving and on direct course to collide, it was too late to avoid the collision.

At 04:01:15, HNoMS Helge Ingstad collided with the tanker Sola TS. The first point of
impact was Sola TS’ starboard anchor and the area just in front of HNoMS Helge
Ingstad’s starboard torpedo magazine. HNoMS Helge Ingstad suffered extensive damage
along the starboard side.

3.3 Organisational and systemic factors

3.3.1 The frigate and the Navy

a) Organisation, leadership and teamwork on the bridge of HNoMS Helge Ingstad were
not expedient during the period leading up to the collision. The watch changes
between the officers of the watch and the officer of the watch assistants, the night
meal and the rotation of positions between the bridge crew team coincided with the
training in optical positioning.

b) The Navy lacked procedures to ensure the functioning of the bridge team while
administering training. The training activity being conducted for two watchstanding
functions reduced the bridge team’s capacity to address the overall traffic situation,
and the officer of the watch lacked assistance for operating important bridge systems.

c) The Navy lacked competence requirements for instructors. The Navy had assigned
the officer of the watch a role as instructor which the officer of the watch had limited
competence and experience to fill. Furthermore, the Navy had not given the officer of
the watch assistant sufficient training and competence to operate important bridge
systems while training the officer of the watch assistant trainee at the same time.

d) As a consequence of the clearance process, the career ladder for fleet officers in the
Navy and the shortage of qualified navigators to man the frigates, officers of the
watch had been granted clearance sooner, had a lower level of experience and had
less time as officer of the watch than used to be the case. This had also resulted in
inexperienced officers of the watch being assigned responsibility for training. The
level of competence and experience required for the lean manning concept (LMC),
was apparently not met.

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e) A more coordinated bridge team with more information sharing would have been
more capable of detecting the tanker sooner. Achieving good teamwork is particularly
challenging in the case of bridge teams whose members are constantly being replaced.
Furthermore, the bridge team was part of a culture characterised by great confidence
in each other’s skills, and this may have contributed to the perception of them being
in full control of the situation and thus less vigilant and sensitive to weak signals of
danger.

f) The governing bridge service documents (the bridge manual) provided insufficient
job support with regards to risk assessment and ensuring a safe voyage. The
navigational aids, the bridge design and the bridge manual were not optimised to
ensure the best possible situational awareness on the bridge.

g) The bridge team was not correctly put together with regards to the requirements for
vision in current regulations. It may be questioned whether the Navy’s system for
medical selection and follow-up was satisfactory.

h) The bridge team on HNoMS Helge Ingstad may have been somewhat affected by
fatigue, particularly considering the time of day. The Navy lacked systematic logging
of working hours and hours of rest. The Ministry of Defence has initiated the process
of establishing protective provisions for sea-going personnel in the Navy.

i) According to the Navy’s regulations for the use of AIS, AIS shall, as a rule, be in
transmission mode and special vigilance shall be exercised when deviating from the
rule. After 2014, the use of AIS in passive mode had generally become more of a rule
than an exception on the Fleet’s vessels, as a consequence of an ever more demanding
security policy situation, without any specific guidance being provided on
compensatory measures.

j) If the frigate had set AIS to mode 3 for the voyage, it’s highly likely that the VTS
monitoring system would have displayed the AIS information. The investigation has
found that the dialogue between the NCA and the Navy about the use of W-AIS in the
Fedje VTS area, faded away before guidelines for such use were in place.

k) After the accident, the Navy has implemented relevant measures relating to safety
culture, navigation, technical safety, documentation, competence management and
handling of nonconformities (see Appendix H), as well as teamwork training, medical
requirements and fitness.

3.3.2 The tanker and the shipping company

a) It is a known fact and normal practice that tankers approaching the terminal need to
start preparing for mooring and loading, and that vessels leaving the terminal work on
securing for sea. The shipping company had not established compensatory safety
measures with regards to the reduction of the visibility of the navigation lights due to
deck lighting, and claims that the current practice is safe. The AIBN is of the opinion
that to the extent that the visibility of the navigation lights is reduced this may pose a
risk.

b) Radar plotting and communication between the bridge crew and the pilot on the
bridge did not sufficiently ensure the effect of active teamwork to build a common

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situational awareness. This could have increased the time window for identification
and warning of the frigate.

c) After the accident, the shipping company has not implemented changes in connection
with any of the possible areas of improvement relating to its vessels that have been
identified by this investigation. This concerns use of deck lights and the shipping
company’s own navigation procedures with pilot on board.

3.3.3 The Norwegian Coastal Administration, the VTS and the pilot services

a) When the pilot has the most active role on the bridge, while the bridge team assumes
a more standby role, the corrective effect of active teamwork to build up a common
situational awareness, can be reduced. This is to some extent in line with findings in
previous investigations. The AIBN has previously issued a safety recommendation50
on this subject to the Norwegian Coastal Administration.

b) Lack of monitoring meant that the VTS operator’s situational awareness and
overview of the VTS area were inadequate. In combination with night work, the VTS
operators’ duties can cause a weakening of the ability to concentrate. The
functionality of the monitoring system with regards to automatic plotting, warning
and alarm functions, was not sufficiently adapted to the execution of the vessel traffic
service. The NCA had not established human, technical and organisational barriers to
ensure adequate traffic monitoring.

c) Traffic monitoring is necessary to ensure that the VTS centres have sufficient scope
of action to operate an early, effective and safe traffic organisation and information
service. The night of the accident, the VTS centre’s scope of action had largely been
lost when the VTS once again became aware of the presence of HNoMS Helge
Ingstad.

d) Fedje VTS did not adequately inform other traffic in the area of Sola TS leaving the
Sture Terminal. An efficient and correct information service is an important
contribution to situational awareness on all vessels when tankers operate within the
VTS area. Due to the lack of traffic information the frigate’s bridge team missed an
opportunity to register that a tanker was leaving the Sture terminal.

e) The introduction of AIS and electronic charts may have contributed to establishing a
general expectation among seafarers that other vessels have a complete overview of
the traffic situation. In turn, this might have given rise to the view that there was less
need for the VTS centre to provide information. It might also have contributed to less
manual radar plotting of vessels on the part of VTS.

f) It is not given that the introduction of a traffic separation scheme in the Hjeltefjord
will improve maritime safety for the area as a whole. Any introduction of traffic
separation in the fairway must also be considered in relation to what challenges it can
create for traffic entering and leaving other fairways to and from Bergen, and in
relation to whether traffic organisation by Fedje VTS can provide the same degree of
safety.

50
Safety Recommendation Marine no 2010/04T in Report Marine 2010/01.

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4. SAFETY RECOMMENDATIONS
The investigation of this marine accident has identified 15 areas in which the AIBN
deems it necessary to submit safety recommendations for the purpose of improving safety
at sea.51

Safety recommendation MARINE No 2019/05T

On the southbound voyage in the early hours of 8 November 2018, training was being
conducted for two watchstanding functions on the bridge of HNoMS Helge Ingstad. The
training activity meant that the bridge team’s capacity to address the overall traffic
situation was reduced. The Navy lacked competence requirements for instructors and
procedures to ensure the functioning of the bridge team while administering training.
The Accident Investigation Board Norway recommends that the Royal Norwegian Navy
establish competence requirements and procedures for training activity on the bridge,
attending to both the training function and safe navigation.

Safety recommendation MARINE No 2019/06T

On the southbound passage through the Hjeltefjord in the early hours of 8 November
2018, while training activity was being conducted on the bridge of HNoMS Helge
Ingstad, the navigator in charge did not pick up on the signals of danger or that the
navigator’s own situational awareness was inaccurate. A more experienced navigator
would have been better equipped to realise this. As a consequence of the clearance
process, the career ladder for fleet officers in the Navy and the shortage of qualified
navigators to man the frigates, officers of the watch had been granted clearance sooner,
had a lower level of experience and had less time as officer of the watch than used to be
the case.
The Accident Investigation Board Norway recommends that the Royal Norwegian Navy
consider the career path and the clearance process for officers in the Fleet in relation to
the Navy’s manning concept for frigates, with a view to ensuring that bridge teams have a
sufficient level of competence and experience.

Safety recommendation MARINE No 2019/07T

On the southbound passage through the Hjeltefjord in the early hours of 8 November
2018, a more coordinated bridge team on HNoMS Helge Ingstad would have been more
capable of detecting the tanker sooner. Achieving good bridge resource management
(BRM) is particularly challenging in the case of bridge teams whose members are
constantly being replaced.
The Accident Investigation Board Norway recommends that the Royal Norwegian Navy
establish systematic bridge resource management (BRM) training for the whole bridge
team.

Safety recommendation MARINE No 2019/08T

On the southbound passage through the Hjeltefjord in the early hours of 8 November
2018, the tanker was not detected in time to avoid the collision. Organisation, leadership
and teamwork on the bridge of HNoMS Helge Ingstad were not expedient. In addition,

51
The investigation report is submitted to the Ministry of Trade, Industry and Fisheries, which will take the necessary
steps to ensure that due consideration is given to the safety recommendations.

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the governing bridge service documents (the bridge manual) provided insufficient job
support with regards to risk assessment and ensuring a safe voyage.
The Accident Investigation Board Norway recommends that the Royal Norwegian Navy
review and revise the governing bridge service documents.

Safety recommendation MARINE No 2019/09T

The investigation of the collision in the Hjeltefjord in the early hours of 8 November
2018, has found that the personnel on the bridge on HNoMS Helge Ingstad was not
correctly put together with regards to the requirements for vision in current regulations.
Medical fitness assessment and follow-up is meant to ensure that everyone who serves in
a given position, is medically fit to perform such service safely and effectively.
The Accident Investigation Board Norway recommends that the Royal Norwegian Navy
review and improve its system for medical fitness assessment and follow-up with regards
to vision.

Safety recommendation MARINE No 2019/10T

On the southbound passage through the Hjeltefjord in the early hours of 8 November
2018, HNoMS Helge Ingstad sailed with AIS in passive mode. This meant that the vessel
could not be immediately identified on the screens at Fedje VTS and Sola TS. It was a
challenge for maritime safety that the Navy was able to operate without AIS transmission
and without compensatory safety measures within a traffic system where the other
players largely used AIS as their primary source of information.
The Accident Investigation Board Norway recommends that the Royal Norwegian Navy
review the use of AIS and ensure that adequate compensatory measures are put in place
when using AIS in passive or encrypted mode.

Safety recommendation MARINE No 2019/11T

If HNoMS Helge Ingstad had set AIS to mode 3 (Warship AIS) for the voyage in the
early hours of 8 November 2018, it’s highly likely that the VTS monitoring system would
have displayed the AIS information. The investigation has found that the dialogue
between the NCA and the Navy about the use of W-AIS in the Fedje VTS area, faded
away before guidelines for such use were in place. The AIBN considers use of W-AIS in
VTS areas to potentially be a valuable safety barrier in situations where use of AIS mode
1 is not appropriate.
The Accident Investigation Board Norway recommends that the Royal Norwegian Navy,
in cooperation with the Norwegian Coastal Administration, resume and formalise their
combined effort to develop and implement guidelines for the use of Warship AIS in the
Fedje VTS area, as well as in other Norwegian VTS areas as required.

Safety recommendation MARINE No 2019/12T

On the southbound passage through the Hjeltefjord in the early hours of 8 November
2018, HNoMS Helge Ingstad sailed with AIS in passive mode. This meant that the vessel
could not be immediately identified on the screens at Fedje VTS or the displays on Sola
TS. When operational demands led to a change of practice to more use of AIS in passive
mode, the applicable rules in the navigation requirements were set aside.
The Accident Investigation Board Norway recommends that the Royal Norwegian Navy
review the operating concept and ensure that safety management and operational needs
are compared as management parameters.

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Safety recommendation MARINE No 2019/13T

The access to factual information in order to map the sequence of events in the collision
in the Hjeltefjord in the early hours of 8 November 2018, has been somewhat limited by
the lack of Voyage Data Recorder (VDR) on board HNoMS Helge Ingstad. Had VDR
data from HNoMS Helge Ingstad been available, the AIBN would have had access to
unique data to document the sequence of events more exactly, and to better understand
the situation on board the frigate.
The Accident Investigation Board Norway recommends that the Royal Norwegian Navy
install VDR on the Navy’s vessels.

Safety recommendation MARINE No 2019/14T

The investigation of the collision in the Hjeltefjord in the early hours of 8 November
2018, has found that the bridge team on HNoMS Helge Ingstad may have been somewhat
affected by fatigue, particularly considering the time of day. In the absence of systematic
logging of working hours and hours of rest etc., it has not been possible to further
investigate the degree to which the bridge team may have been affected by fatigue. The
Ministry of Defence has initiated the process of establishing protective provisions for sea-
going personnel in the Navy.
The Accident Investigation Board Norway recommends that the Ministry of Defence
introduce, particularly relating to critical functions, a system to give the Navy a
systematic overview and positive control of hours of rest. In addition, a requirement for
compensatory measures should be put in place when non-compliance with the provided
hours of rest in the civilian protective provision.

Safety recommendation MARINE No 2019/15T

When leaving the Sture Terminal in the early hours of 8 November 2018, Sola TS had the
forward-pointing deck lights turned on to light up the deck for the crew who were
securing equipment etc. for the passage. The deck lights reduced the visibility of both the
navigation lights and the flashes from the Aldis lamp. This contributed to the bridge team
on HNoMS Helge Ingstad not managing to visually identify Sola TS as a vessel.
The Accident Investigation Board Norway recommends that the shipping company
Tsakos Columbia Shipmanagement S.A. establish safety measures for the use of deck
lights on vessels, which ensures that the deck lights do not reduce the visibility of the
navigation lights.

Safety recommendation MARINE No 2019/16T

During the voyage from the Sture Terminal in the early hours of 8 November 2018,
neither HNoMS Helge Ingstad nor any other vessels were plotted on the radar on Sola
TS. Furthermore, there was little communication between the bridge team and the pilot
about the voyage and the general traffic situation in the fairway. This meant that the
effect of active teamwork to build a common situational awareness was not sufficiently
ensured.
The Accident Investigation Board Norway recommends that the shipping company
Tsakos Columbia Shipmanagement S.A. review and improve its practice relating to
cooperation on the bridge and safe navigation on vessels under pilotage.

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Safety recommendation MARINE No 2019/17T

The investigation of the collision in the Hjeltefjord in the early hours of 8 November
2018, has found that Sola TS’ deck lights reduced the visibility of both the navigation
lights and the flashes from the Aldis lamp. This contributed to the bridge team on
HNoMS Helge Ingstad not managing to visually identify Sola TS as a vessel. It is a
known fact and normal practice that the tankers on their way to the terminal need to start
preparing for mooring and loading, and that the vessels on their way out prepare for the
ocean-going voyage.
The Accident Investigation Board Norway recommends that the Norwegian Maritime
Authority address the industry in general with regards to the use of deck lighting which
could reduce the visibility of the vessel’s navigation lights.

Safety recommendation MARINE No 2019/18T

In the early hours of 8 November 2018, the VTS centre did not monitor the southbound
voyage of HNoMS Helge Ingstad through the Hjeltefjord. The NCA had not established
human, technical and organisational barriers to ensure adequate traffic monitoring. The
functionality of the monitoring system with regards to automatic plotting, warning and
alarm functions, was not adapted to the execution of the vessel traffic service.
The Accident Investigation Board Norway recommends that the Norwegian Coastal
Administration review and improve how traffic monitoring is conducted, with regards to
manning, tasks and technical aids.

Safety recommendation MARINE No 2019/19T

In the early hours of 8 November 2018, Fedje VTS did not adequately inform other
traffic in the area of Sola TS leaving the Sture Terminal. An efficient and correct
information service is an important contribution to situational awareness for all vessels
when tankers operate within the VTS area. Due to the lack of traffic information the
frigate’s bridge team missed an opportunity to register that a tanker was leaving the Sture
terminal.
The Accident Investigation Board Norway recommends that the Norwegian Coastal
Administration review and improve its procedures and practice for traffic information.

Accident Investigation Board Norway

Lillestrøm, 7 November 2019

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5. FURTHER INVESTIGATIONS
The AIBN will continue the investigation into how and why HNoMS Helge Ingstad ran
aground and sank.

The main areas for the AIBN’s further investigation are (this list is not complete):

- Mapping of the battle damage repair.

- Investigation of how the systems for propulsion and steering were functioning after
the collision.

- Investigation of cooperation and internal communication in the accident situation on

board HNoMS Helge Ingstad.

- Investigation of possible connections linked to design criteria/choices for the Fridtjof

Nansen-class frigates. This includes e.g. an investigation of the design with hollow
propeller shafts.

- Detailed stability calculations for HNoMS Helge Ingstad.

- Further examination of the bilge system on HNoMS Helge Ingstad.

- Investigation of what decision-making support was available to the crew in the

accident situation and cooperation with dedicated onshore organisation.

This work presumes continued good collaboration with the responsible organisations,
primarily the frigate manufacturer Navantia, the Navy and the Norwegian Defence
Materiel Agency, and that the AIBN is being given unhampered access to relevant
information.

As a result of the scope and complexity of the investigation, it is not possible to estimate
a date of completion for the part two report. The investigation still has a high priority.

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DETAILS OF THE VESSELS AND THE ACCIDENT

Vessel 1
Name HNoMS Helge Ingstad
Flag state Norwegian
Classification society DNV-GL, put into class 24 November 2014
Call signal LABI
Type Frigate
Build year 2009
Owner Norwegian State Ministry of Defence
Operator Royal Norwegian Navy
Construction material Steel
Length 133.25 m
Port of departure
Destination port Dundee, Scotland
Persons on board 137
Vessel 2
Name Sola TS
Flag state Malta
Classification society DNV-GL
IMO Number/Call signal 9737383/9HA4475
Type Crude oil tanker
Build year 2017
Owner Tsakos
Operator / Responsible for ISM Tsakos Columbia Shipmanagement (TCM) S.A.
Construction material Steel
Length 249.9 m
Gross tonnage 62,557 tonnes
Port of departure The Sture Terminal
Destination port Tetney, UK
Cargo Oil
Persons on board 24
Information about the accident
Date and time 8 November 2018, 04:01:15 local time
Type of accident Collision
Location/position where the
The Hjeltefjord, N 60°38.5, E 004°51.9
accident occurred
Place on board where the The bow of Sola TS and the starboard side of
accident occurred HNoMS Helge Ingstad aft of midship
Injuries/deaths Minor injuries to 7 persons on board HNoMS
Helge Ingstad
Damage to vessel/the Minor foreship damage on Sola TS.
environment On HNoMS Helge Ingstad, approximately 46 m of
the ship’s starboard side was torn open.
Ship operation Inshore voyage
At what point of the voyage was
Under way
the vessel
Environmental conditions Southerly breeze, good visibility, night darkness

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REFERENCES
Adams M. R. (2006): Shipboard Bridge Resource Management. Nor’easter Press.

Boitsov S. & Klungsøyr J. (2019): Oljeforurensning i Hjeltefjorden etter forliset av KNM Helge
Ingstad. Rapport fra Havforskningen 2019-24.

Endsley, M. R. (1995). Toward a Theory of Situation Awareness in Dynamic Systems. Human

Factors, 37(1), 32–64. https://doi.org/10.1518/001872095779049543

Hærem, T. & Rau, D. (2007). The influence of degree of expertise and objective task complexity on
perceived task complexity and performance. Journal of Applied Psychology, 92(5), 1320-1331.

International Maritime Organization (2011): International Convention on Standards of Training,

Certification and Watchkeeping for Seafarers. STCW. Including 2010 Manila Amendments. IMO,
London.

Chabris, C. F. & Simons, D. J. (2011). The invisible gorilla: And other ways our intuitions deceive
us. Harmony.

Swift A. J. (2004): Bridge Team Management, a practical guide. 2nd Revised edition (2004),
Nautical Institute.

Wahl, A.M. & Kongsvik, T. (2018): Crew resource management training in the maritime industry:
a literature review. WMU Journal of Maritime Affairs (2018) 17:377-396
https://doi.org/10.1007/s13437-018-0150-7.

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ABBREVIATIONS
AIBN Accident Investigation Board Norway
AIS Automatic Identification System
ARPA Automatic Radar Plotting Aid
BRM Bridge Resource Management
BTM Bridge Team Management
COSWP Code of Safe Working Practices for Merchant Seafarers
COG Course Over Ground
CPA Closest Point of Approach
CSOC C-Scope Operator Client
DAIBN Defence Accident Investigation Board Norway
DINA Distribution of Navigation Signals
DSC Digital Selective Calling
ECDIS Electronic Chart Display and Information System
ERM Engine Resource Management
FOS Armed Forces’ admission section
FOST Flag Officer Sea Training
GPS Global Positioning System
GT Gross tonnage
HM Helmsman
HNoMS His/Her Norwegian Majesty’s Ship
IMO International Maritime Organization
INS Information Service
IPMS Integrated Platform Management System
ISM International Safety Management
JRCC Joint Rescue Coordination Centre
KDA Kongsberg Defence and Aerospace
LMC Lean Manning Concept
MFD Multi Functional Display
MPX Master Pilot Exchange
NAS Navigation Assistance Service
NATO North Atlantic Treaty Organization
NavKomp The Navy’s Navigation Competence Centre
NDMA Norwegian Defence Material Agency
NDLO Norwegian Defence Logistics Organisation

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nm Nautical mile (1 nm = 1,852 m)

NPM Navigation Procedures Manual
OOW Officer of the watch
OOWA Officer of the watch assistant
OOWAT Officer of the watch assistant trainee
OOWT Officer of the watch trainee
OPUS Operational periodical qualification sea
OSS Operational Support System
Port LO Port lookout
SLVTS Centre for pilotage and vessel traffic service
SMCP Standard Maritime Communication Phrases
SNMG1 Standing NATO Maritime Group One
SOG Speed Over Ground
SOLAS Safety Of Life At Sea
STANAG NATO Standardization Agreement
STBD LO Starboard lookout
STCW Standards of Training, Certification and Watchkeeping for Seafarers
TCM Tsakos Columbia Shipmanagement S.A.
TCPA Time to Closest Point of Approach
TOS Traffic Organisation Service
VDR Voyage Data Recorder
VHF Very High Frequency (30-300 MHz)
VTS Vessel Traffic Service
XO Executive officer

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APPENDICES
Appendix A: Data from the Norwegian Meteorological Institute

Appendix B: Fatigue, sleep deprivation and circadian rhythm

Appendix C: Excerpts from key instructions for Fedje VTS

Appendix D: Eyesight tests – methods and regulations

Appendix E: DNV GL – Survey of the safety culture in the Fleet and among the Navy’s executive
staff

Appendix F: Photos from the observation voyage

Appendix G: Cognitive and organisational challenges in a navigation team

Appendix H: Measures implemented by the Royal Norwegian Navy

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 Accident Investigation Board Norway APPENDIX A

APPENDIX A – DATA FROM THE NORWEGIAN

METEOROLOGICAL INSTITUTE

Observations from weather stations in the area around the time of the accident on 8 November 2018.
Source: The Meteorological Institute

Observations from weather stations in the area around the time of the observation voyage on 2 April 2019.
Source: The Meteorological Institute
 Accident Investigation Board Norway APPENDIX A

Numerical ocean model of current conditions in the Hjeltefjord at the time of the accident. Source: The
Meteorological Institute
 Accident Investigation Board Norway APPENDIX B

APPENDIX B – FATIGUE, SLEEP DEPRIVATION AND

CIRCADIAN RHYTHM
General observations on fatigue

How tired we get and human cognitive functions such as observation, assessment, planning and
taking action depend on two fundamental neurobiological processes in the body (Satterfield and
Killgore, 2019):

1. The homoeostatic process, an automatic regulation mechanism whereby the need for sleep
increases with the period of wakefulness (sleep deprivation). Sleep will once again reduce
the need for sleep.

2. The circadian process, which has to do with how the body’s biological clock (the body’s
natural 24-hour rhythm) affects the need for sleep. Our body temperature follows a
circadian rhythm. It reaches its lowest point (nadir) in the early hours of the morning,
normally between 04:00 and 06:00. After that, our body temperature rises until sometime
between 13:00 and 15:00, and remains at a stable high level until sometime between 20:00
and 22:00, when its starts to drop towards nadir. We usually sleep from approximately six
hours before until approximately two hours after body temperature nadir. It is difficult to
stay awake around nadir. The ability to sleep is low just after nadir, somewhat higher
between 14:00 and 17:00 and then drops again until it normally starts to rise between 21:00
and 01:00 (Pallesen & Bjorvatn, 2009).

For an individual to get enough quality sleep over time, these two processes must function well –
both separately and in relation to each other. This means that fatigue is the combined result of the
homoeostatic and circadian processes.

The need for sleep

The amount of daily sleep needed to avoid running a sleep backlog will vary from one individual to
another (the National Competence Centre for Sleep Disorders1):

The need for sleep varies considerably from one individual to another. When considering
our own sleep pattern, it is therefore important to look beyond the number of hours of
sleep that we get. The quality of sleep, i.e. the number of hours of deep sleep, is even more
important than the total number of hours of sleep. The general rule is that we get enough
sleep if we feel rested during the day. This applies regardless of the number of hours of
sleep we get during the night.

For some individuals, less than six hours of sleep can be enough, while others need nine
hours or more to function well the following day. Both can be seen as normal, even if such
sleeping hours are uncommon. It is important to remember that people differ in many
ways, in height, weight and appearance as well as their need for sleep. Looking at the
population as a whole, adults sleep an average of between 7 and 7.5 hours, and the vast
majority sleep between 6 and 9 hours.

1
See https://helse-bergen.no/nasjonal-kompetansetjeneste-for-sovnsykdommer-sovno/normal-sovn
 Accident Investigation Board Norway APPENDIX B

In the USA, the National Sleep Foundation2 keeps abreast of research into the need for sleep in
different age groups. For adults aged 18 and above, they now recommend 7–9 hours of sleep and
that consideration be given to the quality of sleep and not just the number of hours of sleep.

How long it takes to recover after running a sleep backlog varies. Sleep during the day is generally
of poorer quality than regular sleep at night, and is therefore not equally suited for restitution from
sleep deprivation. Studies by Åkerstedt et al. (2000) show that a good night’s sleep is seldom
enough to make up for sleep deprivation, two nights is usually enough to feel rested and up to the
mark, while three or four nights are needed to recover after a period of material disruption of the
circadian rhythm.

Fatigue also varies with the time of day. The most important time sensor in the circadian rhythm is
light. Much light reduces melatonin levels and the need for sleep, while dark surroundings increase
melatonin production and the need for sleep (Stehle et al., 2011). For most people, the need for
sleep increases around 22:00 and reaches a peak between 03:00 and 06:00. In the daytime, the need
for sleep increases slightly sometime in the early afternoon, and then drops again until the next
night cycle begins.

The following is stated in a review by the Institute of Transport Economics of studies of fatigue in
seafarers on civilian vessels (Phillips, 2014):

The sleep patterns of seafarers are relatively well documented, and both sleep quantity and
quality are poor, especially for those working the popular 6/6 watch. Average total sleep
lengths per day seem to center around 6 to 7 hours for many crew, but this sleep is often
taken in two or more spells. Continuous sleep periods of desired length are rare.

Fatigue and functional capacity

It is documented in a number of studies that operators who are affected by sleep deprivation clearly
have a higher risk of accidents than others. For example, a study among road users showed that less
than six hours of sleep before starting work entailed a fourfold increase in the accident risk, and less
than four hours of sleep multiplied the risk by 19. Less than 12 hours of night-time sleep in the
course of the last two days before starting work increases the probability of a fatigue-related
accident (Philips & Sagberg, 2010).

Research has shown that individuals who stay awake for more than 16 hours or get less than 6 hours
of sleep per night tend to show persistent and profound impairment in sustained attention
(Satterfield & Killgore, 2019). Trials have also shown that reducing sleep by one hour per night for
a week had adverse effects that it took more than three days of normal sleep to remedy. In one
study, it was found that two weeks of four hours’ sleep per night led to an inattentiveness that was
comparable to 88 hours without sleep. Several studies have also demonstrated that 18 hours of
wakefulness can be compared with a blood alcohol content of 0.05 per cent.

Studies (Satterfield and Killgore, 2019) also show that the circadian rhythm has an impact on the
effect of long periods of wakefulness. In the early afternoon, the circadian rhythm will have the
positive effect of reinforcing the feeling of being awake, while it will have the negative effect of
reinforcing the feeling of sleepiness during the early hours of the morning.

VanLeuwen et al. (2013) conducted a trial by simulating the maritime watch system and measuring
the degree of fatigue after exposing the subjects to both sleep deprivation and circadian disruptions.

2
www.sleepfoundation.org
 Accident Investigation Board Norway APPENDIX B

One third of the participants in the trial fell asleep on at least one watch in the course of the
simulated week-long structure. The highest number of subjects fell asleep on the 00–04 watch, and
the number of subjects who fell asleep increased after overtime work and restricted possibilities of
sleep. The trial documented how the circadian rhythm and a need for sleep accumulated over time
had the combined effect of increasing fatigue and heightening the risk of accidents within the
framework of the simulated maritime watch system.

The Bridge Watchkeeping Safety Study (2004) by the UK Marine Accident Investigation Board
(MAIB) reviewed in detail the evidence of 66 collisions, near collisions, groundings and other
incidents investigated by the MAIB between 1994 and 2003. One of the findings in the study was
that a third of all the groundings involved a fatigued officer alone on the bridge at night.

Characteristic effects of fatigue

Fatigue, i.e. the combined effect of wakefulness and the time of day, has three characteristic effects
(Satterfield and Killgore, 2019):

1. Sleepy individuals are unstable and unpredictable. It is to some degree possible to

compensate for the lack of sleep, but often for only part of the work at hand. Satterfield
and Killgore (2019) describe this as follow:

Together, these data illustrate that performance instability is a hallmark of sleep loss. It is
this unstable and unpredictable nature that makes fatigue so dangerous, especially in
safety-critical operations.
Doran et al. (2001) made similar findings:

Cognitive impairment due to sleep loss does not constitute a gradual performance decline
or a complete failure to perform, but rather takes the form of performance instability.
2. Sleepy individuals pay less attention to changes in their surroundings and less attention to
the quality of their own work.

3. Wakefulness over time impairs physical and mental resources.

Based on the available research, it appears to be quite clear that fatigue leads to unpredictability and
instability, particular in executive functions. These functions are located in the frontal lobe, an area
of the brain that, among other things, helps us to handle multiple thoughts and ideas simultaneously,
think before we act, handle unexpected situations and stay concentrated.

The following effects of fatigue are also documented:

- Fatigue impairs the capacity for self-assessment and individuals will tend to overestimate
their own fitness (Satterfield and Killgore, 2019).

- They will tend to pay attention to what they assume to be the most important factors in a
situation, and thus apply a top-down strategy. They will lack flexibility and will not take
much note of new factors, and they will have a high threshold for doing anything other
than planned tasks (Whitney et al., 2018).

- Individuals affected by fatigue are able to maintain quality in the performance of some
tasks, but they have to put more effort into the work (Gould et al., 2009). This reduces their
ability to perform tasks other than their primary tasks, i.e. secondary tasks. They take less
Accident Investigation Board Norway APPENDIX B

note of nonconformities in their own performance, and will to a greater extent deviate from
procedures without being aware of it.
 Accident Investigation Board Norway APPENDIX C

APPENDIX C: EXCERPTS FROM KEY INSTRUCTIONS FOR

FEDJE VTS
The instructions for the Information Service (INS) at Fedje VTS state the following, among other
things:

The VTS operator shall provide an information service that ensures that information that is
deemed to be relevant for the transit becomes available in time for on-board navigational
decision-making. Procedures should be in place at minimum to ensure that the VTS issues
transit-related information as necessary when:
 vessels enter the VTS area;
 vessels start to move within the VTS area;
 vessels anchor in the VTS area;
 the VTS operator deems it necessary;
 a vessel requests information.
The VTS operator shall perform the information service so as to give vessels an overview of
traffic that could affect their transit (message marker ‘Informasjon’ /‘Information’), including
vessels that can be expected to approach from the opposite direction, cross the course line,
overtake or be overtaken by the vessel. It is particularly important that vessels approaching,
catching up with or crossing each other’s course lines are informed of this when visibility is
poor.
Such information shall be limited to a factual description of the observations made.
Information about traffic that can affect the transit should be relevant, and for example
consist of the position, identity, intention and destination of a vessel. When the information
concerns several vessels/ conflicts, only the number of vessels should be stated. When there is
a lot of information to be conveyed, it should be broken down into several messages and made
available in time for on-board navigational decision-making.
The instructions for the Navigation Assistance Service (NAS) at Fedje VTS state the following,
among other things:

Navigational assistance shall be given when situations arise in which:

 a moving vessel requests navigational assistance;
 the VTS operator deems it necessary.
Examples:
 Risk of running aground or collision
 Vessel deviating from the passage plan
 Technical failure of a vessel’s navigational equipment
 Vessel uncertain of its position
When a situation arises in which the VTS operator deems it necessary to provide navigational
assistance, the VTS operator shall provide information, recommendations and instructions as
necessary to ensure safe transit. The VTS operator shall continually monitor the vessel’s
transit and the effect of the information, recommendations and instructions given.
 Accident Investigation Board Norway APPENDIX C

The VTS operator shall continually assess factors that may have an impact on how the
navigational assistance is performed. When a VTS operator considers that a vessel is at risk
of collision or grounding or otherwise poses a threat to fairway safety, the VTS operator may
instruct the vessel to change course or speed (message marker ‘Instruksjon’/‘Instruction’) to
prevent a situation of distress. Such instructions may be used when the VTS operator finds it
necessary to prevent loss of human life or injuries, or damage to the environment or property.
A VTS operator who considers the time aspect to be particularly critical in a situation may,
for example, instruct a vessel to steer to a particular course when that is considered
necessary to avoid a situation of distress.
The instructions for the Traffic Organisation Service (TOS) at Fedje VTS state the following,
among other things:

2.1 Monitoring of the areas covered by Fedje VTS

Fedje VTS shall continuously monitor traffic within its VTS area for the purpose of detecting
situations in which there is a danger of collision or grounding.
In the monitoring of the VTS area, priority shall be given to the following in particular:
 navigationally challenging areas where, based on experience, the risk of incorrect
navigation is particularly high;
 narrow fairways with approaching or passing traffic, including fairways where the
Maritime Traffic Regulations contain provisions on passing in the same or opposite
direction;
 areas of crossing traffic where, based on experience, there is a risk of proximity
situations/collision, for example the Hjelteskjær area, Fedjeosen and
Holmengrå/Grimeskjæret;
 vessels carrying hazardous or noxious cargo between Sture, Mongstad and the pilot
embarkation areas;
 continuous monitoring of vessels in transit subject to traffic organisation or
navigational assistance, including monitoring of the traffic situation and the effect of
the information, recommendations and instructions given;
 continuous monitoring of situations of approaching or crossing traffic under
conditions of poor visibility, for example at Brosmosen, Fedjeosen, Vatlestraumen
and Kobbarleden.
Monitoring of the Fedje VTS area shall also detect vessels that:
 enter the VTS area or leave a quay or anchorage site;
 move in contravention of the permissions given by the VTS centre;
 whose navigation markedly or persistently deviates from the expected/instructed
route;
 come into a proximity situation / risk collision;
 are moving in contravention of the provisions of the Maritime Traffic Regulations;
 are drifting at anchor.
The VTS operator shall ensure that vessels carrying hazardous or noxious cargo use the
mandatory fairway in accordance with Section 124. Vessels carrying hazardous or noxious
cargo with a gross tonnage of more than 30,000 tonnes shall normally use the shortest
Accident Investigation Board Norway APPENDIX C

fairway (Fedjeosen to/from Sture, Holmengrå to/from Mongstad). The VTS operator shall
normally grant vessels carrying hazardous or noxious cargo with a gross tonnage of less than
30,00 tonnes permission to choose where to navigate within the mandatory fairway.
In general, the VTS operator shall seek to facilitate that large tankers can complete their
planned passage without being obstructed by other traffic. This means that the VTS operator
shall seek to keep other traffic at a safe distance from the tanker.
…
2.5.3 The Grimstadfjord (Haakonsvern) / the Raunefjord / Vatlestraumen
This area is at times heavily trafficked by military vessels, which often sail without AIS or
VHF radio notification.The VTS operator must pay special attention to this.
 Accident Investigation Board Norway APPENDIX D

APPENDIX D: EYESIGHT TESTS – METHODS, REGULATIONS,

SELECTION
Method

The eyesight tests were carried out by the Norwegian Centre for Maritime Medicine (NSMM), a
section of the Department of Occupational Medicine, University Hospital of Bergen, based on the
following methods:

Visual acuity

Optec 6500 with ETDRS charts, luminance 85 candela/m2 (cd/m2)[1] for the right eye, left eye, and
both eyes, respectively, at a simulated distance of 6 metres. Visual acuity is presented in decimal
Snellen fractions, in line with the notations used in the regulations. For candidates wearing glasses,
corrected visual acuity was also measured. ETDRS charts are in everyday use. The charts have
limitations when assessing eyesight quality other than visual acuity, and no strong correlation is
found between visual acuity and functional ability in day-to-day tasks or specific maritime tasks.

Colour vision

Colour vision was assessed by the CIE 143-2001 standard (International Recommendations for
Colour Vision Requirements for Transport). The assessment includes use of Ishihara-24 plates with
interpretation of plates 2–13, the Hardy-Rand-Rittler Pseudoisochromatic Plate Test 4th Edition
(HRR4), the Farnsworth D15 dichotomous test, and the Optec 900 lantern test.

The candidates were also assessed using the computer-based Colour Assessment and Diagnosis
(CAD) test method. The CIE colour vision standard is based on the consensus of an international
panel of experts in 2002. The test instruments used alone are not sufficient to diagnose and quantify
colour vision defects, but, combined, they provide a basis for determining the candidate’s level of
functioning. The Ishihara test, which is used by most maritime doctors, has a high negative
predictive value for red-green colour vision impairments. CAD has a high negative predictive value
for red-green and blue-yellow colour vision defects and is suitable for determining the candidate’s
level of functioning and for use in diagnostics.

Contrast sensitivity (contrast vision)

Contrast sensitivity is assessed by Optec 6500, using sine-wave gratings at 1.5 to 18 cycles per
degree of visual angle (cpd) for light levels of 3 cd/m2 (twilight), 3 cd/m2 (twilight with glare) and
85 cd/m2 (daylight), respectively.

The findings are assessed at individual spatial frequencies and an index of contrast sensitivity (ICS).
No generally accepted standard is available as the first choice for measuring contrast sensitivity.

Still, the applied method is preferred for evaluation of contrast sensitivity, both for scientific and
empirical reasons. The various frequency bands are responsible for different parts of image
formation in the brain. Low frequencies cover image formation of large, rough structures, while
higher frequencies provide detail to the image. The index of contrast sensitivity was developed to
simplify the interpretation of frequency data; threshold values of individual frequencies and their
importance concerning the quality of vision are not well established. No absolute minimum
threshold values for any measurement of contrast sensitivity has been determined concerning
 Accident Investigation Board Norway APPENDIX D

occupational requirements. Normative data exists for ICS and frequency data for the relevant group
in connection with the use of OPTEC 6500.[2] ICS observed for each candidate is presented as a
percentile of the ICS for normal data. And the frequency data are discussed for each candidate. No
normative data are available for ICS or frequency measurements for twilight glare exposure
(3cd/m2). This exposure is, therefore presented with the normal data for twilight conditions. ICS
and contrast sensitivity is expected to be slightly reduced under glare conditions.

Refraction

Refraction was measured in dioptre (D) using a NIDEK autorefractor based on the average of three
measurements per eye. The method indicates refractive disorders but is not fully adequate as the
basis for producing optimum corrective glasses or contact lenses.

Rules and regulations

Minimum medical fitness standards exist for personnel who perform specific services in the Armed
Forces. The standards are intended to ensure that the personnel have the health qualifications
required to work with adequate safety. Medical fitness requirements can be broken down into two
main categories: requirements relating to the absence of any illness that might reduce the quality of
the service, and standards for sufficient competence (in terms of eyesight, hearing etc.) to perform
the service.

Regulations on medical examination of employees on ships

The Regulations on medical examination of employees on Norwegian ships and mobile offshore
units, state that any person working on a Norwegian ship must be medically fit for service onboard
and not endanger the health and safety of other persons on board. In the regulations, the Ministry of
Trade, Industry and Fisheries has stipulated specific eyesight requirements for the different
categories of employment onboard ships.

The regulations set out requirements for assessment of visual acuity (distance vision/near vision),
colour vision, reading vision, visual angle, night vision, double vision and contrast sensitivity (on
indication). The Armed Forces’ vessels are not exempt from these regulations.[3]

A specialist assessment is required if reduced night vision is suspected. Following refractive eye
surgery and other ophthalmological procedures, which may potentially impair eyesight, an
examination by a specialist shall be carried out after the vision is presumed to have stabilised. The
aim is to map any occurrence of reduced contrast vision, reduced night vision, halo, starburst or
similar effects.

Provisions on military health service and medical assessments (FSAN P6)

In addition to the Regulations on medical examination of employees on ships, Regulation on

military health service and medical assessments (Bestemmelse for militær helsetjeneste og
legebedømmelse – FSAN P6) apply to the selection and follow-up of Armed Forces personnel. The
Regulation has been drawn up by the Armed Forces’ medical service to ensure uniform
classification and selection of military personnel, to safeguard the health of personnel and thereby
ensure the Armed Forces’ combat capacity.

Regulations restrict the possibility of performing military service with illnesses and functional
impairments. FSAN P6 guides the medical fitness standards issued by the different branches of the
 Accident Investigation Board Norway APPENDIX D

Armed Forces. FSAN P6 stipulates normative restrictions in fitness for service in a specified list of
diseases of the eye and visual acuity.

Instructions concerning medical requirements for the Navy

The guidelines concerning medical fitness standards for the Navy (Instruks om helsekrav for
Sjøforsvaret) apply to all personnel serving in the Navy or participating directly in the Navy’s
activities. The purpose is to ensure that personnel do not suffer from any illness, injury or handicap
whereby situations could arise that pose a risk to their own or other personnel’s health and safety.
The instructions specify medical requirements for the different services based on FSAN P6 and the
given assessment figures.

The instructions state that personnel serving onboard a ship shall meet the requirements in the
regulations. The guidelines set out specific standards for eyesight and colour vision based on FSAN
P6. For officers, the corrected visual acuity shall be at least 1.0 for each eye, and the uncorrected
visual acuity shall be at least 0.5 for the best eye and 0.3 for the poorest eye (assessment figure: 7).
Colour vision shall be normal.

Personnel who have undergone refractive eye surgery shall present specialist documentation of
preoperative and postoperative visual acuity, including contrast vision, and information about the
procedure, before they can be assessed as fit for service at sea by a military doctor.

[1] Candela (cd) is the unit of measure for luminance.

[2] Koefoed, VF (2015): Contrast sensitivity measured by two different test methods in healthy,
young adults with normal visual acuity.
[3] Regulations relating to the application of the Ship Safety and Security Act by the Ministry of
Defence’s subordinate agencies.
 Accident Investigation Board Norway Appendix E

APPENDIX E: DNV GL – SURVEY OF THE SAFETY

CULTURE IN THE FLEET AND AMONG THE NAVY’S
EXECUTIVE STAFF
Competence and manning:

The main impression is that the Navy has robust competence in the different discipline
areas. The main challenges associated with competence and manning are first and
foremost characterised by issues relating to a shortage of the right resources and a
strong perception of safety being ensured through procedures and good preparedness.
In addition to professional competence, a mature safety culture requires that all
employees in the organisation have sufficient safety competence based on an overall
system perspective. This is found to be somewhat weak in the Navy.

Cooperation and involvement:

In general, the Navy is good at cooperating. People work towards common

operational goals and are well aware of each other’s competencies and
responsibilities. The most important challenges identified in the area of teamwork and
involvement have to do with the assumption that others are in control and carry out
tasks in the best possible manner, and that individual crew members find it
challenging to signal that an operation should be stopped or changed. These
assumptions can cause an individual to refrain from communicating signals to other
officers or the vessel’s management. In addition, it is left to the willingness of the
vessel’s management to respond to the signals. The ability to signal and the
willingness to act on signals can both constitute challenges to safety.

Alertness:

The combination of good education, belief in oneself and others, respect for rank (as
regards competence) and experience of success (including with a view to safety) can
contribute to a high level of complacency. This can impede the ability to stay alert.
The need to look out for the unexpected or to continuously use new information to
adjust one’s own and others’ decisions is not always assigned enough importance.

Conflicting goals:

The Navy has generally been observed to have few safety goals in place for its vessels
and operations. Weak and few safety goals for the vessels and operations mean that
there are often no conflicting goals (which is not always a good thing). This weakens
any counter-pressure from the safety culture (see section 2.2.6 Conflicting goals in a
safety perspective, ‘drift to danger’) to strike a balance between operational goals and
efficiency goals. If the pressure from the need to perform/complete operations
becomes too great, the safety margins can be ‘eaten up’, which can lead to
undesirable incidents and accidents.

Incentives:

There are clear incentives in place for operational success and for advancing one’s
career in the organisation. At the same time, there are few formal and uniform
 Accident Investigation Board Norway Appendix E

incentives relating to safety. Low status of risk assessment qualifications and safety
competence can result in little motivation to focus on risk assessments in general or on
incident reporting and improving own competence relating to safety. The organisation
has few incentives in place for cultivating certain disciplines and the critical roles of,
for example, navigators, and this results in navigation officers serving for a short time
and quickly advancing to other roles.

Compliance:

No specific challenges have been defined relating to compliance, but certain

impairments exist as a consequence of challenges relating to other dimensions
(Incentives and Robustness), which are analysed and discussed under those headings.

Robustness:

Lack of clarity about how to observe and apply rules and regulations can impair the
development of robustness in the organisation in the form of building robustness
through systems and processes. As a result of the possibility of using exceptions under
current regulations, together with lack of clarity on the part of the Navy about how to
observe and apply rules and regulations, many people feel that ‘the rules and
regulations do not apply to us’. This cultural aspect can affect the safety of personnel
and vessels in that it underpins the perception that ‘it is acceptable to push the limits
to deliver on our commitments’, and thereby, without being aware of it, exceed what
would have been the acceptance limits or tolerance criteria for risk had such criteria
been established. The perception that safety is maintained through procedures and
good preparedness also undermines the demand for safety goals and impedes the
development of safety management.

Organisational learning:

Organisational learning refers to systematic reflection on improvement potential, and

thus changing performance. The challenge here is the perception that the work often
consists of taking risks, at the same time as it is believed that safety is maintained
through procedures and good preparedness. In addition, there is a perception that
safety is maintained at vessel level. Underreporting of near-misses and inconsistent
handling of reported non-technical incidents mean that the organisation misses out on
an important source of learning. Furthermore, distribution and feedback on reported
incidents varies from one vessel to another and between the different types of vessel.
 Accident Investigation Board Norway Appendix F

APPENDIX F: PICTURES FROM THE OBSERVATION

VOYAGE
As stated in Chapter 1.15.3.2 of the report, an observation voyage took place with Sola TS and
HNoMS Roald Amundsen on the night of 2 April 2019. The voyage was accomplished by the frigate
being in a series of waypoints "Romeo 1" to "Romeo 13". The table below shows the waypoints the
frigate sailed through and the approximate corresponding time of the accident voyage.

Planned distance and bearing from HNoMS Roald Amundsen to Sola TS also appear in connection
with each waypoint. In the pictures that are from each of the waypoints, the Sola TS is highlighted
with a yellow circle.

The voyage was planned so that HNoMS Roald Amundsen should be in the position that HNoMS
Helge Ingstad was in the night of the accident while Sola TS should be in the points the vessel was in
when it departed from the quay at the accident night. As stated in Chapter 2.1.2.3 of the report, the
sea current and wind conditions on the night of April 2 meant that Sola TS came somewhat faster
around to a northerly course and was therefore somewhat closer to the frigate than was the case the
night the accident took place.

Waypoint Corresponding time the night Bearing/range HNoMS

of the accident (approx. time Roald Amundsen - Sola TS
hour, minute)
Romeo 1 (Fig.1) 03.38 163/7.66
Romeo 2 (Fig.2) 03.41 163/6.91
Romeo 3 (Fig.3) 03.46 163/5.49
Romeo 4 (Fig.4) 03.48 163/4.72
Romeo 5 (Fig.5) 03.50 161/4.02
Romeo 6 (Fig.6) 03.51 161/3.70
Romeo 7 (Fig.7) 03.52 161/3.36
Romeo 8 (Fig.8) 03.53 161/3.02
Romeo 9 (Fig.9) 03.54 161/2.67
Romeo 10 (Fig.10) 03.55 161/2.21
Romeo 11 (Fig.11) 03.56 161/1.92
Romeo 12 (Fig.12) 03.57 161/1.55
Romeo 13 (Fig.13) 03.58 161/1.35
 Accident Investigation Board Norway Appendix F

Figure 1. HNoMS Roald Amundsen passing waypoint "Romeo 1". Source: Police/Navy

Figur 2. HNoMS Roald Amundsen passing waypoint "Romeo 2". Source: Police/Navy
 Accident Investigation Board Norway Appendix F

Figur 3. HNoMS Roald Amundsen passing waypoint "Romeo 3". Source: Police/Navy

Figur 4. HNoMS Roald Amundsen passing waypoint "Romeo 4". Source: Police/Navy
 Accident Investigation Board Norway Appendix F

Figur 5. HNoMS Roald Amundsen passing waypoint "Romeo 5". Source: Police/Navy

Figur 6. HNoMS Roald Amundsen passing waypoint "Romeo 6". Source: Police/Navy
 Accident Investigation Board Norway Appendix F

Figur 7. HNoMS Roald Amundsen passing waypoint "Romeo 7". Source: Police/Navy

Figur 8. HNoMS Roald Amundsen passing waypoint "Romeo 8". Source: Police/Navy
 Accident Investigation Board Norway Appendix F

Figur 9. HNoMS Roald Amundsen passing waypoint "Romeo 9". Source: Police/Navy

Figur 10. HNoMS Roald Amundsen passing waypoint "Romeo 10". Source: Police/Navy
 Accident Investigation Board Norway Appendix F

Figur 11. HNoMS Roald Amundsen passing waypoint "Romeo 11". Source: Police/Navy

Figur 12. K HNoMS Roald Amundsen passing waypoint "Romeo 12". Source Police/Navy
 Accident Investigation Board Norway Appendix F

Figur 13. HNoMS Roald Amundsen passing waypoint "Romeo 13". Source: Police/Navy

Figur 14. Visible objects that could be observed from the bridge of HNoMS Roald Amundsen during
the observation voyage. Source: Police/AIBN
 Accident Investigation Board Norway APPENDIX G

APPENDIX G: COGNITIVE AND ORGANISATIONAL

CHALLENGES IN A NAVIGATION TEAM

Report to the Accident Investigation Board Norway

By Svein S Andersen, Thorvald Hærem and Dominique Kost

(The authors are listed alphabetically, but have contributed equally.)
 Accident Investigation Board Norway APPENDIX G

About the authors

Svein S Andersen is a professor of organisational studies at BI Norwegian Business School. He has
previously been head of the Department of Leadership and Organizational Behaviour and Dean for
BI’s PhD programmes. He earned his PhD degree at Stanford University based on a dissertation on
the organisation of petroleum activities in the North Sea. One of the main topics was how to
organise activities so as to leave no room for serious incidents and errors. Theoretical perspectives
are mindful organisations and reliable experiential learning. This touches on key challenges in
modern organisations, which have to cope with uncertainty and change. One of his main interests in
terms of methods is case studies. He has published a vast number of international articles and
books. In the last few years, he has taught BI’s management programme ‘Organizing for the
unexpected’ together with Thorvald Hærem.

Thorvald Hærem is a professor of organisational psychology at BI Norwegian Business School, and

wrote his PhD on how experts and novices solve problems in organisations. He teaches
organisational theory and how people make decisions at the individual, team and organisation level.
His areas of research cover the same topics. The results of his research have been published in
leading international journals such as Academy of Management Review, Journal of Applied
Psychology, Organization Studies, Journal of Behavioral Decision Making, Leadership Quarterly,
Management of Information Systems Quarterly and Organization Science.

Dominique Kost is an associate professor of organisation and management at OsloMet – Oslo

Metropolitan University. She presented her PhD thesis in 2016 at BI Norwegian Business School.
Before she started on her PhD, she worked as a personnel management consultant. Her areas of
research are virtual teams, communication in crisis situations and digital work. Dominique’s PhD
thesis concerned performance and coordination of knowledge in virtual teams. She also studies
digitalisation and new work methods. Dominique’s areas of teaching are management, personnel
management and digital management.
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Contents:
Purpose and structure of the report ............................................................................................ 1
What is a team? .......................................................................................................................... 2
Teams as organisation ........................................................................................................... 2
Team structure and sharing of information ........................................................................... 3
Attention, perception and selection............................................................................................ 4
Distinguishing between foreground and background ............................................................ 4
Changes in situational awareness ......................................................................................... 5
Team level .............................................................................................................................. 6
Situational awareness (SA) and transactive memory systems (TMS) ....................................... 8
Situational awareness ............................................................................................................ 8
Rigid situational awareness ................................................................................................... 9
Transactive memory systems (TMS) .................................................................................... 10
Sensemaking and decision-making biases ............................................................................... 12
Information richness and selective perception .................................................................... 12
Excessive confidence in own knowledge, and confirmation bias ........................................ 14
Mindful interaction .............................................................................................................. 15
Sharing of information and weak signals ............................................................................ 16
Routines as carriers of knowledge and interaction competence .............................................. 17
Routines as practice ............................................................................................................. 17
Mindful and mindless information processing ..................................................................... 18
Brief summary and discussion ................................................................................................. 19
List of references...................................................................................................................... 21
 Accident Investigation Board Norway APPENDIX G

Purpose and structure of the report

The point of departure are the priorities emphasised in the letter of assignment. The purpose is to
contribute a set of theoretical premises for understanding how the bridge team on ‘KNM Helge
Ingstad’ functioned during the period leading up to the accident. The incident was complex and multi-
faceted and diversely perceived by those involved. The AIBN’s interviews, factual description and
mapping of the sequence of events have identified safety problems arising from mistakes and
misconceptions, and a lack of barriers. This report sheds light on mechanisms that can help to explain
how these types of mistakes and misconceptions arise, and how they can be rectified.

The theoretical perspectives described in this report entail various supplementary approaches. They
can be used as the point of departure for further analyses of important human and organisational
factors that affect perceptions, assessments and the actions chosen at both the individual and team
level. The weighting of perspectives and different explanatory mechanisms provided in the report
reflects actual events as described in the available data material.

The first part concerns the question: What is a team? It provides a framework for understanding the
importance of the factors that can affect a bridge team’s capacity for establishing and updating a
reliable situational awareness. Factors such as experience, age and fatigue can affect several of the
factors discussed.

The second part, Attention, perception and selection, highlights factors that affect our ability to pick
up on different stimuli, or signals, in our surroundings. What is attention? What characterises
inattentiveness and change blindness? What are the human limitations when it comes to judging
distances to lights/objects in the dark?

The third part covers the literature on mental models and situational awareness (SA). What is a mental
map? What is situational awareness at the individual and team level? How can certain mental schemas
and models lead to a rigid situational awareness?

The fourth part, Sensemaking, explains some key factors relating to how mental models work. How
can individuals in interaction with other team members strengthen their capacity for picking up on
and interpreting weak signals that are inconsistent with established expectations? This is important in
relation to people’s ability to update and develop their situational awareness.

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The fifth part, Routines as a carrier of knowledge and teamwork competence, explores topics such as
the interaction between internalised routines and non-internalised routines, and how internalised
routines can be processed to free up cognitive capacity to search for signs of possible deviations from
expected patterns.

What is a team?
Teams as organisation
In traditional organisation theory, roles were designed based on the tasks to be performed – and
individuals filled predefined roles. This way of thinking was characterised by a hierarchical
organisation and clearly defined lines of command. This tradition completely dominated both
industrial and military organisations for a long time. Based on this way of thinking, social psychology
developed an interest in how to create dynamic and efficient organisations (e.g. Katz & Kahn, 1966).
In addition, team theory gradually gained a firmer foothold in organisational theory, especially the
part of organisational theory that concerned non-standardised tasks; tasks that demand active
attention, situational awareness and fresh thinking. The literature on organisations that cannot afford
to fail, known as high reliability organisations (HRO), combines insight from social psychology with
organisational theory. Although the HRO perspective does not include a specific team perspective, it
emphasises challenges relating to reliable perception, interpretation and learning in situations
characterised by complexity and ambiguity. A main focus is how to recognise and manage the
unexpected through mindful interaction and sharing of knowledge and information (Weick & Sutcliffe,
2015).

Teams are different from both groups and formal organisational entities. Teams have been defined in
different ways (Bass, 1982; Baum et al. 1981; Denson, 1981; Dyer, 1984; Hall & Rizzo, 1975). In a
comprehensive study of team behaviour in the US Navy, a team was defined as a set of two of more
individuals who interact interdependently and adaptively to achieve specified, shared and valued
objectives (Morgan et al., 1986). The study pointed out that the interaction between individuals was
partly determined by interaction with machines and machine procedures, leaving too little room for
communication and cooperation between the team members, both during training and in the
performance of their tasks. This has enabled the performance of tasks to become standardised and
routinised. At the same time, it can weaken the mechanisms that create the very dynamics and
flexibility that strengthen a team’s capacity to handle uncertainty and ambiguity. This weakens the
team’s ability to pick up on situational elements that fall outside known patterns of variation.

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Team structure and sharing of information

How do procedures affect teams working in situations characterised by complexity and ambiguity? In
a team, team members have a primary responsibility for specific roles, while roles are performed in
interaction, taking account of both the primary responsibility of other team members and the team’s
overriding objective. A team that works this way creates dynamics that strengthen teams’ capacity to
continuously pick up on nuances and deviations in ambiguous situations and thereby deal with
unexpected incidents before they become critical. This way of thinking is based on the belief that
neither the leader alone nor any individual member of the team can be absolutely certain that they
have perceived all important factors in the situation correctly. Sometimes, it can be useful to establish
teams within the team in order to attend to core tasks. Research into teams also recognises that
people are fallible. This is a key point in research into bounded rationality and capacity for reliable
learning (March & Simon, 1958; Kahneman, 2011; Weick, 1979). Such a basic view is clearly reflected
in research on aviation safety (Helmreich, 2000) and is also an underlying assumption in the theory of
reliable organisations (Weick & Sutcliffe, 2015).

Normally, misconceptions will sometimes arise about situational elements, which could undermine
the bigger picture and the team’s shared situational awareness. A study of aviation safety showed
that, on average, such situations arose twice during a flight, but that they usually were corrected
(Helmreich, 2000). Active interaction and sharing of information increase the possibility of clearing up
misconceptions and identifying signals of danger at an earlier stage (Weick, 1990; Weick & Sutcliffe,
2015). What is special about communication that leads to accidents is not that misconceptions arise
but that they are not corrected.

Stasser and Titus (1985) started a stream of research into team communication. They discovered that
it is fairly common for critical information not to be shared, precisely because people assume that
others have the same information or that the information is unimportant. A meta study on
information sharing shows that sharing of unique information is particularly critical to the outcome
when the exchange of information is highly structured (Mesmer-Magnus & DeChurch, 2009).

An accident that illustrates the phenomenon of not sharing information and difficulties in perceiving
approaching light signals is described by Perrow in the book ‘Normal Accidents’ (1986). The master of
a coast guard vessel misinterpreted a ship’s lights as lights from a vessel they were catching up with,
while the lookout correctly perceived the lights to be from a ship approaching in the opposite
direction. The lookout thought the master shared this perception and did not say anything. As the

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master thought he was about to overtake the ship they were catching up with, he decided to provide
more room for manoeuvring as they were approaching the mouth of the Potomac River, and made a
sudden turn to port. As a result of this, the coast guard vessel collided with an approaching cargo ship.

A team that is part of a hierarchical structure required to be capable of handling complexity and
ambiguity in dynamic environments can give rise to challenges. The contrast between maintaining a
robust focus and being susceptible to signals that can refute or modify the established situational
awareness is particularly challenging.

Attention, perception and selection

Distinguishing between foreground and background
Attention, perception and selection of information in organisations have been widely elucidated in
studies on cognitive limitations and bounded rationality (Neisser, 2014; Weick, 1979; Simon & March,
1958; Tversky & Kahneman, 1974; Kahneman, 2011). Perception is about whether and how individuals
perceive and process external stimuli (see e.g. Schacter, Gilbert & Wegner, 2009). Sensitivity to
different stimuli reflects general human characteristics, but can be affected by experience, training,
organisational culture and routines. Essential in this context is the ability to identify and understand
changes that may significantly affect the interpretation of situations. This ability has received
considerable attention in studies of military personnel, and also in the transport sector. Keywords are
attentional limitations and change blindness. Since the late 1940s, it has been common knowledge
that some types of change are sometimes overlooked because they are camouflaged by familiar and
easily recognisable main patterns.

A classic example is Bruner and Postman’s (1949) experiment, in which the colours of playing card
suits – such as hearts and spades – were switched. It turned out that there was a strong tendency for
the card suit shape to be more dominant than colour, so that, for example, red spades were identified
as spades. Mazza and Turato (2005) show that changes can be camouflaged by ‘drowning’ in
foreground or background patterns, so that it becomes difficult to distinguish objects from the
foreground or background. One explanation is that automated cognitive processes relating to the
recognition of main patterns are less demanding than extracting information from variations within
such a pattern.

We know from research into road safety in the USA that drivers are often blind to unexpected road
users. For example, the most frequent accident situation encountered by motorcyclists is when a car
crosses the opposite lane to turn left. Car drivers check whether the road is clear by looking for cars

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approaching in the opposite direction. If no cars are approaching, they make the turn, failing to detect
and recognise any oncoming motorcycles (Hurt, Ouellet & Thom, 1981, quoted in Simon & Chabris,
2011). This was and continues to be a dangerous situation for motorcyclists. A total of 65% of accidents
involving motorcyclists occur in situations where the other vehicle violates the motorcyclist’s right-of-
way (Simon & Chabris, 2011). Simon and Chabris coined the phrase ‘inattentional blindness’ to
describe this blindness to the unexpected.

Another classic example of inattentional blindness is Simon and Chabris’s (2011) ‘invisible gorilla test’.
The participants in an experiment were asked to watch a video of two teams of students passing a
basketball around. They were asked to count the number of passes made between players wearing
white. At one point in the video, a person wearing a gorilla suit appears between the players, beats
his chests and leaves the area. After watching the video, the participants were asked whether they
noticed anything out of the ordinary. Alternatively, they were asked directly whether they noticed a
gorilla in the video. It turned out that 46% of the participants failed to notice the gorilla. Simon and
Chabris explain this as a manifestation of ‘inattentional blindness’.

The problem is not that the gorilla is difficult to see – quite the contrary. It is an example of a
phenomenon called selective attention control. Those involved do not notice special or unexpected
events because their attention is focused on one task in such a way that other situational elements
are filtered from their awareness. The overall picture, and any changes to the overall picture, do not
become part of their continuously updated situational awareness.

Changes in situational awareness

There are several mechanisms that can contribute to maintaining a gradually more incorrect
situational awareness. The focus on training specific skills can draw attention away from weak signals
of danger, in the same way as counting basketball passes distracts attention from signals that the
gorilla is moving through the group of players.

Even in, for example, a well-known training situation, training in specific skills can distract from more
actively seeking information to confirm or adjust the overall picture of the situation. This is in line with
findings by Chen (2008) and Chen and Treisman (2008), which have shown that the likelihood of not
registering a change object increases with the object’s distance from the focus of attention.

One type of study on attention concern people’s perception of the size and speed of changes. Big and
rapid changes are, naturally, easier to identify. Small, gradual changes can be associated with change
blindness, however. The likelihood of detecting objects increases if the object is moving towards

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rather than away from the observer (Cole & Liversedge, 2006). In cases where the observer moves
relatively quickly towards the object, however, this may camouflage the object’s movement. The
above example from Perrow (1984) illustrates precisely the fact that moving towards an object giving
off light can make it more difficult to determine the movement of that light.

Another factor relating to awareness at the individual level is that, even when we have surplus
cognitive capacity, we continue to employ economising mechanisms as long as possible, even if the
usefulness and quality of our choices become sub-optimal. Research has shown that, using heuristics,
we make choices where simple reflection or calculation could give us a better range of choices
(Gigerenzer, 2000 and Kahneman, 2011).

Team level
In organisations, attention is a scarce resource. Organisations economise on attention. Basic
organisational theory (Simon & March, 1958) claims that people often make endeavours to think and
act rationally, but that they only manage to do so to a limited degree. Our capacity and ability to search
for, process, store and retrieve information is limited. Organisations therefore develop routines and
procedures to rationalise the processing of information, for example to select and deselect both
relevant and irrelevant signals, interpretations and options for action. Organisations are required to
steer attention towards certain things, at the same time as other situational elements become less
important. Strong programming of this type has major advantages when the tasks and surroundings
are stable and well understood. Given variable tasks and surroundings, however, situational
awareness requires more active, open searching for and updating of information. Extensive research
shows that striking a good balance can be challenging (March & Simon, 1958; Scott, 2015).

Newby and Rock (1998) distinguish between two paths to attentional focus and situational awareness.
One main path is top-down processing of observations. This is characterised by active search for
certain stimuli and patterns that match the internalized expectations of the organisation’s members.
To varying degrees, such individual expectations may be overlapping reflecting education, training and
experience. This type of search mode is sensitive to weak stimuli, as long as such stimuli are consistent
with expectations. Inconsistent stimuli or signals are more easily overlooked, and there is thus a
tendency to perceive what is seen as confirmation of having understood the situation correctly.

Another path to situational awareness is bottom-up processing of observations. This means that the
search process is triggered by stimuli or signals that are not automatically understandable, but that
activate a search for pattern recognition. Ensuring that signals are not ignored requires a certain signal
strength and information richness on which further identification and interpretation can be based.

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Both perception and interpretation can be more demanding in such situations. The capacity to detect
the unexpected can be overruled by routines, but can be strengthened through exercise at the
individual and team level.

Psychology is not the only discipline that has studied such mechanisms. Sociologist Thorstein Veblen
(1914) introduced the term ‘trained incapacity’ to describe how professional knowledge can limit
people’s perspective: ‘that state of affairs in which one’s abilities function as inadequacies or blind
spots’. This means that training and experience can lead people down the wrong path when faced
with new situations or new elements that can challenge their established conceptions. Rochlin (1991)
uses the term ‘scenario fulfilment’ to describe the misconceptions that caused the US Navy vessel
‘Vincennes’ to accidentally shoot down an Iranian passenger plane in 1988.

Limited attention can be seen as economising with scarce resources, and is the first phase of the
perceptual cycle (Neisser, 2014; Weick, 1979). It entails a selection of signals or indicators for further
processing. Specific and targeted reporting (communication) between roles entail economising with
one’s own and others’ time and attention. Rationalising the use of time drives rationalisation of
attention in other areas.

Challenges relating to attention and the ability to detect critical factors in a situation can be reinforced,
but also impeded, through organisational measures. This is well documented in research, but the
documented effects are not absolute. It is a question of propensities or probabilities, and may vary
from person to person and from one situation to the next. This means that individuals in a team can
perceive stimuli in different ways. Some will perceive and interpret critical signals correctly, while
others will misperceive such signals and some will ignore them completely.

In a well-functioning team, characterised by open and honest sharing of observations, the effect of
mistakes and misconceptions by individuals can be corrected (Helmreich, 2000, pp. 781–784). Even if
someone misunderstands or ignores important signals, the team can develop a realistic situational
awareness. Furthermore, a hierarchical context and lack of communication training can give rise to
expectations and create barriers to the utilisation of diversity in observations and approaches. Rochlin
(1991:116–17) points to organisational challenges relating to the perception and integration of
different situational elements in dynamic and ambiguous situations. In the study of ‘USS Vincennes’,
he describes what the officers on the bridge refer to as ‘having the bubble’, meaning to establish and
maintain an overall reliable situational awareness. It was clearly communicated who had ‘the bubble’
at any time.

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Another general challenge in teams is to develop and maintain shared models for understanding
situations. Perception is about placing stimuli in mental models and thus generating observations that,
in turn, form the basis for situational awareness. The ability to create a realistic, nuanced situational
awareness depends on which models are mobilised and how nuanced they are. This makes creating a
correct common situational awareness a complex and challenging task. This is addressed in the section
below.

Situational awareness (SA) and transactive memory systems (TMS)

There are many different forms of mental models in teams, but two in particular are important to
shedding light on individuals and teams’ role comprehension, cooperation and adaptive ability,
namely situation awareness (SA) and transactive memory systems (TMS), or shared information about
own and others’ knowledge and expectations.

Situational awareness
Endsley (1995) originally studied situational awareness among air traffic controllers and was
interested in explaining how they were able to retain control of the situation, with the air full of planes
scheduled for landing and the airport full of planes scheduled for take-off. The term has later been
used in organisations engaged in land, sea and air operations, and in all organisations involved in crisis
management and defence tasks. Both Endsley and others have subsequently taken an interest in how
this situational awareness is handled by teams. What is their shared situational awareness?

Situational awareness (SA) is defined as: ‘the perception of environmental elements and events with
respect to time or space, the comprehension of their meaning, and the projection of their future
status’ (Endsley, 1995, p. 36, 2015). As indicated by the definition, the model can be broken down into
three levels: Level 1 – perception of the elements in the environment, Level 2 – comprehension of the
relationship between these elements, Level 3 – projection of future developments and events
(Endsley, 1995).

A recent study looked at the relationship between Level 1, 2 and 3 SA, and team performance (Valaker,
Hærem & Bakken, 2018). It found that Level 2 and 3 SA are more important in explaining performance
than Level 1 SA, while Level 1 SA is related to the building of Level 2 and 3 SA.

The same study also found that it is more difficult to integrate Level 2 and 3 SA (directly critical to the
result) when communication takes place in a distributed setting – in other words not co-localised and
face to face.

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At the individual level, role comprehension, knowledge and job performance skills are important
factors in developing situational awareness. Experience and expertise influence what information we
seek, how it is interpreted and, finally, our situational awareness (Endsley, 1997; Endsley, 2006).

At team level, it is important to distinguish between shared situational awareness, i.e. the degree to
which the team has a shared understanding of the surroundings, and accuracy, i.e. whether this shared
understanding of the surroundings is correct (Salmon et al., 2008). In other words, a team’s shared
understanding of the surroundings is not necessarily an accurate understanding. The teams situational
awareness covers not only an understanding of the tasks to be carried out, but also the coordination
processes between the team members (Salas, Prince, Baker & Shrestha, 1995).

Situational awareness at the individual and team level are linked. If a team member perceives new
information about the surroundings and communicates it to the rest of the team, SA is also developed
at team level (Salas et al., 1995). Information sharing also works as a control mechanism. When team
members share or coordinate their individual understanding of the situation, it is possible to make
corrections to the team’s situational awareness. If critical elements of information are missing, the
whole team can develop a shared, but incorrect understanding of the situation. Critical elements of
information are related to the dynamic elements of information that are necessary to performing the
task. Situational awareness is not an accurate picture automatically created by individuals who play a
role in a team. Many factors contribute to this.

Rigid situational awareness

An incorrect situational awareness on the part of the team has in fact been a factor in many of the
accidents that have occurred in the Navy. Often one or a few individuals are in possession of critical
information that could have contributed to a more accurate situational awareness. In 13 of 21
groundings with Norwegian MTBs that occurred in the period 1989–2007, members of the navigation
team possessed critical information about the situation that they failed to share (Neverdal, 2017). The
reason why such information is not shared can be the assumption that the information is already know
to everyone, or an expectation that everyone with greater authority would correct any errors in the
shared understanding. That team members fail to share unique information is a well-established
finding in what is known as ‘hidden profile’ research (see Lu, Yuan & McLeod, 2012, for an overview
of relevant literature).

Critical events or situations require teams to acknowledge and communicate changes in the
environment (Burke et al., 2006). In other words, the team must first acknowledge that an assumption

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about the environment is incomplete or incorrect. This will cause the team to look for new information
to form an updated or new understanding of the situation (Waller & Uitdewilligen, 2009).

Research into the relationship between communication media and the ability of information to change
people’s understanding (in the course of a given time interval) has been conducted since the late
1970s and is known as media richness theory (Daft & Lengel, 1986; Dennis & Kinney, 1998; Valaker,
Hærem & Bakken, 2018). A more recent version is called media synchronicity theory (Dennis, Fuller &
Valacich, 2008; Brown, Dennis & Venkatesh, 2010; Valaker, Hærem & Bakken, 2018). The core finding
is that the ability to convey rich information varies between different communication media. Face-to-
face communication is rich because of its high capacity to provide synchronised feedback, to send
multiple signals, to adapt the information to the receiver etc. At the other end of the scale we find
written information, which is considered leaner (less rich) in relation to these properties.

Research on media richness theory and situational awareness (SA) is relevant in this context.
Fundamental to media richness research is the difference between ‘conveyance’ (transmission) and
‘convergence’ (integration) (Dennis, Fuller & Valacich, 2008). It has been established that these two
processes are necessary to achieving a shared understanding. Leaner media such as radio and morse
code are effective for transmitting unequivocal information, but not for integrating equivocal
information into a shared understanding. Face-to-face communication is most effective for
integration.

Transactive memory systems (TMS)

TMS consists of shared knowledge or a shared understanding of who is an expert, plus unique
knowledge that only the expert possesses, as well as the coordination process through which team
members use and update each other’s knowledge. In other words, as a team member, you know who
you must ask to get help. This makes TMS an important part of the coordination of knowledge and
tasks in a team (see e.g. Lewis & Herndon, 2011; Lewis, 2003). A well-functioning team is one where
the team members have different but overlapping cognitive schemas. This applies to teams composed
of domain experts. It will also be the case where team members have different roles – they will
develop specialised schemas for specialised tasks. This will entail a differentiation of schemas – and a
differentiation of TMS. TMS is often confused with the notion of a shared understanding, but it will
often be differentiated with only certain parts shared by the whole team.

Extensive research shows that TMS is important to the team’s performance, learning, creativity and
efficiency (for an overview, see e.g. Ren & Argote, 2011). TMS also stimulates coordination in teams,
a phenomenon that has been studied in e.g. special police forces (Marques-Quinteiro, Curral, Passos

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& Lewis, 2013). At the same time, research has also identified a dilemma for TMS: Too much
specialisation in a team can prevent effective coordination, while a too high degree of coordination
between the team members prevents specialisation of the different roles (Reagans, Miron-Spektor &
Argote, 2016).

Team theory states that individuals with different roles, knowledge and information can develop
different assessments that can make it difficult for the team to establish a shared understanding of
the problem. This research is based on teams characterised by close, binding cooperation on problems
that require fresh thinking and flexibility (see e.g. Majchrzak, Jarvenpaa & Hollingshead, 2007). In a
team with a hierarchical structure, reinforced by some members being experts while others are
novices, the challenges are somewhat different. Research has shown that active information sharing
about each other’s roles helps teams to develop TMS (Pearsall, Ellis & Bell, 2010). Research in this area
also underlines that TMS covers not only the understanding of tasks, but also cooperation and
coordination that is not inherent in the formal roles (Lewis, Lange & Gillis, 2005).

Research into TMS has demonstrated that teams in which members are replaced continue to interact
in the same way as before they were replaced. In other words, new team members are not actively
included in the team’s coordination process and communication, which hampers the team’s
performance and the updating of the TMS (Argote, Aven & Kush, 2018; Lewis, Belliveau, Herndon &
Keller, 2007).

Furthermore, even in a normal watch change between two team members, the handover does not
necessarily include any clarification of role expectations or coordination of information with the rest
of the team, which would help to form the TMS (Pearsall et al., 2010). A new team member may have
a slightly different situational awareness and other assumptions concerning roles and coordination
than the rest of the team, who have just worked with another team member. If the new team member
has a different understanding of roles, expertise and knowledge than the rest of the team, this may
undermine the team’s TMS. This means that it is not sufficient to have routines for or written
information about expertise and roles. This is especially the case in teams whose members change
(Majchrzak et al., 2007).

TMS is a precondition for shared SA, but nonetheless not a guarantee for the SA being accurate and
resulting in good decisions. Below we will take a closer look at how errors and misconceptions in SA
and decisions can arise and how they can be prevented.

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Sensemaking and decision-making biases

Information richness and selective perception

Forming an understanding of one’s surroundings is more than a simple physiological process where
signals are received by sensory organs and generate an accurate picture of the situation. Often,
perception will be partly based on weak, ambiguous signals that need to be interpreted and compiled
to form a picture of the situation. The nature of the situation can change if just one or a few signals
are misinterpreted or ignored (Weick, 1995). Sensemaking is an ongoing retrospective rationalisation
process in which individuals seek and give meaning to their observations and experiences. Active,
mindful updating of one’s situational awareness is critical in environments characterised by change,
uncertainty and ambiguity. A key contributor to the understanding of such processes is Karl Weick
(2001). His model includes three sub-processes: 1) a variation in the surroundings, 2) a selection
process, and 3) a retention process. Each of these sub-processes leaves room for misconceptions, but
also reliable learning:

1) There are vast numbers of elements of information that people can potentially notice – it is
invariably a question of whether all the elements are perceived.

2) Existing cognitive maps activate a selection process in which the signals marked as relevant or
important are selected for further processing. The critical question is whether the importance of the
signals is correctly assessed.

3) This is also how we remember the signals that match our existing cognitive maps. Signals not
marked as relevant are often not stored, in other words ignored – despite the fact that they may have
been selected in the first round.

An important topic that complements research on sensemaking is related to intuitive processing and
decision-making biases (Tversky & Kahneman, 1974; Russo, Schoemaker & Russo, 1989; Kahneman,
2011). A key insight from this research is that people can switch between intuitive and analytical
information processing. Intuitive processing is rapid, parallel, automatic, associative, context-
dependent, and affected by extensive learning and experience. Analytical processing is slower,
sequential, controlled, more context-independent, cognitively challenging, but can be learned quicker
through explicit rules and algorithms (Stanovich & West, 2000).

Many studies find that, after cognitive exertion and mental fatigue, the processing of information will
be more intuitive (see e.g. Pocheptsova, Amir, Dhar & Baumeister, 2009) and less analytical. The strive
for complete analytical processing of all information is reduced in step with the depletion of cognitive
resources. It is not realistic to expect decision-makers to be able to carry out an extensive, complete
analysis of all elements of information in every situation.

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The expression ‘switching cognitive gears’ is used in literature to describe how people’s cognitive
capacity also depends on their ability to switch between different types of cognitive processing, i.e.
from automatic to conscious and analytical processing. People’s ability to understand what type of
processing is required is decisive in critical situations (Louis & Sutton, 1991).

It is a well-established fact that people act as if they use simple rules of thumb to simplify situations
and seek information. Research on decision-making biases draws an important distinction between
simplification heuristics and recognition heuristics (Kahneman & Klein, 2009). Both types are central
to intuitive information processing. They represent different qualities and biases in relation to routines
and interaction (Pentland & Hærem, 2015). Simplification heuristics are the main focus of Tversky and
Kahneman’s research on decision-making biases. It is a common phenomenon and has a central place
in the extensive literature on bounded rationality. Recognition heuristics was one of Herbert Simon’s
interests in seeking to understand the differences between experts and novices’ processing of
information (1987, 1992).

Several areas in the psychology of decision-making have built on and further developed this
research. There is widespread agreement that people handle or reduce this complexity in two main
ways (Kahneman & Klein, 2009; Pentland & Hærem, 2015); through simplification logics and
recognition logics. Simplification logics reduce the complexity, while recognition logics also manage
the complexity to a greater extent.

Simplification mechanisms entail selecting signals in situations that match broad, coarse categories,
or categories that are easily accessible because they are clear or have been extensively or recently
activated. This type of categorisation can activate a third type of simplification mechanism, whereby
information is sought to confirm that the signals are not critical and that the search process can be
concluded.

Recognition mechanisms are to a larger extent based on experience and expertise, where the
reflection is more conscious and goal-oriented. The quality of the pattern recognition is based on
extensive experience, conscious reflection and training in strong expert environments where
challenges are ensured through sufficient variation in the situations that arise. In summary, we can
say that recognition heuristics counteract the tendency towards intuitive simplification.

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Excessive confidence in own knowledge, and confirmation bias

Researchers find that one of the most detrimental cognitive biases is overconfidence. Overconfidence
in one’s own knowledge is the belief that you possess more accurate and reliable knowledge than you
actually do (Kahneman, 2011; Moore & Healy, 2008). Consequently, your belief in the correctness of
your judgements is greater than the objective accuracy of those judgements (Kahneman, 2011; Moore
& Healy, 2008). Overconfidence has a number of effects in addition to the effect of being wrong. It
can reduce information seeking and the analytical processing of information, and thus lead to
misjudgement based on intuitive misconceptions. At the group level, however, the effects seem to be
even greater.

Overconfidence can undermine open communication and thus limit other people’s possibility of
developing good situational awareness. Recent research shows that elaboration of information,
providing increased detail on the core of messages, improves communication and team performance
(Mesmer-Magnus & DeChurch, 2009; Hærem, Valaker & Bakken, 2014). Individuals who have
excessive confidence in their own situational awareness seem to engage less in elaboration – this
becomes especially clear when the communication takes place through rich media, such as face-to-
face communication (Hærem, Valaker and Bakken, 2014).

Kruger, Epley, Parker and Ng (2005) found that overconfidence was driven by, among other things,
egocentrism – i.e. referring to one’s own perspective while neglecting the fact that the rest of the
world does not necessarily share that perspective. Egocentrism is also related to what is referred to
as the fundamental attribution error – i.e. attributing what is going on to ourselves. It is well known
from research on navigation that egocentrism in the design of bridge consoles and instruments affects
situational awareness (Wickens & Prevett, 1995). Wickens and Prevett found that, with an egocentric
design, in other words a design based on the navigator’s perspective on the surroundings, the
navigator would keep a more steady course, while an exocentric design made it easier for the
navigator to identify dangers along the adopted course. Egocentrism and overconfidence can prevent
a good development of situational awareness at the individual level, in addition to affecting
communication (Kruger, Epley, Parker & Ng, 2005) and potentially having a major impact on the team’s
situational awareness.

Strong confidence in own knowledge increases the search for affirmative information. This is called
the confirmation bias. This means that new observations and active searches for new information are
made with a view to confirming the established situational awareness.

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One of the most commonly used strategies in information searches is to search for confirmation that
one is right. This is also the strategy that results in the highest number of decision errors (Nickerson,
1998). Kray and Galinsky (2003) investigated effective strategies for avoiding the confirmation bias
and found that introducing what are known as counterfactual mind-sets – or, in simpler terms, asking
‘what if...’ – was highly effective. When asked ‘What if...’, decision-makers generated alternative
hypotheses that refuted their original hypothesis. This does not happen automatically – but
hypothetical questions will trigger an analytical processing that can generate alternative
interpretations of the situation. Those with high confidence in their own knowledge are not likely to
ask ‘what if I’m wrong and it’s actually this way or that way …’.

Mindful interaction
Inspired by Ludwig Neisser’s (2014) studies of perception as a perceptual cycle, Karl Weick (1979)
developed a model for organisations’ sensemaking processes. One of the main conclusions in that
research was that avoiding confirmation bias is difficult. Individuals and organisations are largely self-
referential systems. Thinking outside our own web of existing knowledge is as difficult as it is to
discredit our own assumptions. A key topic in Karl Weick’s research was how organisations and teams
can avoid being trapped by their initial assumptions by making organisations engage in more mindful
information processing.

Much of the research into human factors and interaction in demanding situations originates in the US
Armed Forces. One officer describes the environment on an aircraft carrier as follows:

Imagine it’s a busy day, and you shrink San Francisco airport to only one short runway and one
ramp and one gate. Make planes take off and land at the same time, at half the present time
interval, rock the runway from side to side and require that everyone who leaves in the morning
returns that same day…Turn off the radar to avoid detection, impose strict controls on the
radio, fuel the aircraft in place with their engines running, put an enemy in the air and scatter
live bombs and rockets around. Now wet the whole thing down with seawater and oil, and
man it with 20-year-olds, half of whom have never seen an aircraft close up…’ (Rochlin, LaPorte
& Roberts, 1987)

‘Although naval aircraft carriers represent a million accidents waiting to happen, almost none of them
do’ (Wilson (1986) in Weick & Roberts (1993). In a classic study of interaction on board an aircraft
carrier, Weick and Roberts (1993) describe how the collective consciousness required by a mindful
organisation is created through heedful interrelating whereby shared mental models are developed.
They describe how shared mental models, the team’s ‘collective mind’, contribute to the formation of
reliable opinions in teams and organisations. A key point in this research is that interaction and

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interactive norms are not primarily formed by written rules and routines – they arise as a result of
observed actions and interaction with others.

The theory on mindful interaction links theories about SA (interpretation of situations) with routines
(patterns of interaction). Together, they point out that mindful interaction can identify early signs that
something has been misconceived, that the situational awareness needs to be adjusted, and that
interaction has taken a wrong course. As previously discussed, it is normal for misconceptions to arise,
but it is also normal for such misconceptions to be corrected.

Interaction and exchange of information are largely controlled by formal roles and rules. In a military
organisation, this basic structure needs to be clear and unambiguous. This provides clarity in complex,
stressful situations. The challenge is that it also limits the possibility of utilising the diversity of
information that individual team members can pick up on.

In organisations with stringent hierarchical and structural elements, interpretation of signals will have
to take place within a fixed framework (Weick, 2001). Behavioural patterns set clear limits for who is
to say what to whom. Communication often goes one way. There will be less room for doubt and for
speaking out if something is perceived as ambiguous, and perhaps wrong, in relation to the situation
being responded to. Research from military and civil aviation shows that active exchange of
information and articulation of doubt can modify the effect of a hierarchy. Such sharing of information
leads to increased vigilance and openness to detecting weak signals before they become a serious
problem. Mistakes will occur, but the capacity for correcting mistakes increases.

Sharing of information and weak signals

Weick and Sutcliffe (2015) talk about how weak signals of danger become strong and clear through a
crystallisation process, but this process requires a certain amount of time. Mindful interaction involves
questioning both individual and shared interpretations. This ensures that assumptions are not taken
for granted. Some degree of uncertainty – not certainty – will therefore often be present in
organisations that have the capacity to handle unexpected situations.

In other words, we intuitively seek information that will confirm our existing mental image. Such
confirmation bias can also be reinforced by overconfidence in one’s own situational awareness, as
discussed above. As a result of these mechanisms, people do not actively consider alternative
explanations. Hærem, Valaker and Bakken (2014) also found that this confidence in own situational
awareness on the part of a team member also spreads to the rest of the team. This applied to both
overconfidence and underconfidence. Such groupthink is a phenomenon partly driven by the search

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for sources of certainty rather than uncertainty. Most of the initial research on groupthink was
conducted in the 1970s (Janis, 1972). It has subsequently been followed up in organisational research
on a regular basis, but it is overconfidence, i.e. people’s ability to develop excessive confidence in their
own abilities, that has received the most attention. A main point in theories on mindful organisations
(Weick & Sutcliffe, 2015) is that people and organisations must systematically cultivate a certain
amount of doubt as to whether they have understood everything correctly. This stimulates vigilance,
which counteracts lack of updating or rigidity in situational awareness.

Routines as carriers of knowledge and interaction competence

Routines as practice

Routines are often defined as repetitive, recognisable patterns of interdependent actions (Feldman &
Pentland, 2003). Routines can be understood at both the individual and organisational level. Here, we
will primarily discuss routines at the organisational level, where the pattern of action is partially
carried out by different individuals. How this takes place in a team is closely connected to the concepts
of mental models and transactive memory systems.

Routines are also important carriers of organisational knowledge. Since efforts are continuously
made to update norms to align them with practice, the interaction between norms and practice is a
key aspect. Norms and practice inform each other. It is not always the case that norms update
practice – it should perhaps just as often be the other way round. Confusion may arise in the
interaction between ideals and practice about the right way to perform a task.

Routines are internalised in different interpretations at the individual level. They are formulated in
ways that enable the development of mutual expectations of behaviour. This makes it possible to
observe deviations and clarify misconceptions and align patterns of behaviour over time. It is often
an advantage for individual routines to be based on a shared understanding of goals and
responsibilities, especially in a closely connected system.

Routines thus comprise both a formal idealised component and a practice-related component.
Examples are idealised descriptions of how jobs are to be performed. How the tasks are actually
performed will often differ from the idealised norm (Feldman & Pentland, 2003). Usually, this
discrepancy will be functional and practice will be more expedient than the idealised norm. The
routine as described seldom matches the situations that arise. Unexpected events require adaptation
and experienced decision-makers who are capable of adapting the routines to the situations that arise
(Suarez & Montes, 2019).

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Mindful and mindless information processing

The point of well-learned routines is that actions can be performed quicker and that it is easier to
keep up with changes in the surroundings. Routinised tasks mean that tasks can be performed
automatically and thereby take up less information processing capacity (March & Simon, 1958). In
organisational psychology, this is often called mindless processing (Pentland & Hærem, 2015;
Laureiro-Martinez, 2014). Mindless processing does not mean that the decision-maker fails to think,
but leaves room for devoting attention to more important factors, such as scanning the surroundings
for signs of deviations from the expected pattern.

More training and experience means that routine tasks take up less attention and free up capacity
for mindful processing of weak signals of potential dangers (March & Simon, 1958; Weick & Sutcliffe,
2014), Mindful processing means to use one’s cognitive capacity to question interpretations of
intuitively accepted information and to conduct activities to detect weak indications that a
nonconformity could be about to arise.

Laureiro-Martinez (2014) defines the degree of mindful processing as the degree of cognitive control
skills employed. The concept stems from neuroscience research and covers cognitive functions of an
‘executive’ kind that allocate attention, control short-term memory, planning and the generation of
options for action, and govern the capacity for reflection (Bargh & Chartrand, 1999; Barkley, 2001;
Laureiro-Martinez, 2014). A practised team strikes a balance between mindless and mindful
processing so that a minimum of cognitive resources are spent on routine tasks and awareness is
allocated to scanning the surroundings and to internal processes to detect threats to continued safe
operation.

Simultaneous training and regular operation is trying for the balance between mindful and mindless
processing. The fact that normal routine tasks are not conducted automatically distracts attention
from other requisite tasks – and occupies the attention of team members who are charged with
ensuring that the training is conducted as planned. This can reduce the capacity that would normally
be spent on looking out for nonconformities and weak signals of unexpected incidents.

Having to review something again reduces the amount of attention available to detect potentially
important signals. Team members get thrown off their routines when things do not go according to
plan, and novices need time to get back into the routine. Experts rarely get thrown off their routine
– and will in any case get back into the routine more quickly (Perrow, 1967; Hærem & Rau, 2007).
This means that novices have much less capacity to look out for weak signals of danger (mindful
processing) than experts. Specific training is particularly important in the case of novices. The

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training should also address how to interpret unclear or ambiguous signals that may be important
and relevant. This requires that the training includes communication and mindful interaction
between all members of the team.

Brief summary and discussion

The purpose is to contribute a theoretical framework that can inform the understanding of how the
bridge team on ‘KNM Helge Ingstad’ functioned during the period before the accident. The report
sheds light on mechanisms that can explain how errors and misconceptions arise and how they can
be corrected. The report outlines several approaches to further analyses of central human and
organisational factors.

The first part concerns how structures, division of labour and procedures govern and limit information
sharing in a team. What challenges create a high degree of structuring in relation to ambiguous and
unexpected elements in the situation.

The second part discusses how attention, perception and selection can give rise to particular
challenges in situations where it is difficult to distinguish foreground from background and detect
weak signals of changes in the situation.

The third part discusses how situational awareness is created at individual and team level. It addresses
challenges associated with developing the three levels of situational awareness at team level, and how
this relates to communication through rich and lean communication media. The second half of this
part discusses how a transactive memory system (TMS) in the team can compile knowledge for
mindful interaction, and points to known challenges in achieving this.

The fourth part discusses how a team interprets weak signals in relation to adjusting or not adjusting
their situational awareness. It also contains a discussion of how people process information intuitively
and analytically – and how intuition can potentially lead to misinterpretations. Two decision-making
biases relevant to establishing situational awareness are also discussed.

The fifth part addresses how routines are translated into practice and how the resultant practice can
be functional or dysfunctional in different settings. It also addresses how learning new routines can
absorb cognitive capacity, thereby reducing the capacity for more active, mindful processing of weak
signals.

In total, we can say that the different parts of the document address different forms of common
perceptual and cognitive limitations and the potential interplay between them in a team. It is a

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challenge for any organisation to deal with human fallibility by strengthening mechanisms that can
clarify mistakes and misconceptions that can arise in situations not fully covered by established action
routines.

All members of the team are required to assume a more offensive, exploratory role in situations
characterised by unclear and ambiguous signals than in familiar situations of little uncertainty and
confusion. All members must be assigned more clearly defined responsibility for contributing to the
overall situational awareness. This also requires a low threshold for sharing and for requesting
supplementary information. Training is needed to maintain efficient, concise communication. Such
training will stimulate both individual and collective capacity while raising each team member’s
awareness of their own and others’ weaknesses and strengths in such situations.

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Accident Investigation Board Norway Appendix H

FORSVARET
Marinen

Marinen viser til kollisjonen mellom KNM Helge Ingstad og Sola TS, 8. november 2018 og den
forestående rapporten fra Statens Havarikommisjon for Transport (SHT). Hensikten med dette skrivet er
å gi en status for de tiltak som er iverksatt i etterkant av ulykken, samt arbeid som pågår for å sikre varig
og bedret sikkerhet for våre fartøy og besetninger.
Vi har iverksatt tiltak på områder hvor svakheter har blitt avdekket, og etterarbeidet er nå over i en
systematisk fase for å identifisere forbedringsområder og sikre varig styrking av sikkerhetsnivået. De
kommende rapportene fra Statens Havarikommisjon, den interne undersøkelses nedsatt av Sjef
Sjøforsvaret og Forsvarsmateriell Maritime kapasiteters (FMA MARKAP) tekniske undersøkelse, vil gi
avgjørende bidrag til dette arbeidet. Inntil disse foreligger har Marinen har valgt å fokusere på
sikkerhetskultur, navigasjon, teknisk sikkerhet, dokumentasjon, kompetansestyring og avvikshåndtering.
Dialogen med overordnede myndigheter for å klarlegge og forbedre de overordnede
rammebetingelsene for sikkerhet håndteres av Sjøforsvarsstaben, herunder klargjøring av roller, ansvar
og myndighet ift skipssikkerhetsloven med tilhørende forskrifter.
Sjøforsvaret har en samhandlingsavtale med Sjef FMA MARKAP hvor det er det gitt at FMA MARKAP er
ansvarlig for teknisk sikkerhet i medhold av skipssikkerhetsloven med tilhørende forskrifter.
For Marinen vil arbeidet fremover ta utgangspunkt i de styrkene Marinen allerede har på
sikkerhetsområdene, med vekt på systematisk trening og sertifisering av fartøyene og seleksjon av
personell til sikkerhetskritiske stillinger, men samtidig være realistisk og selvkritisk i måten vi avdekker
og utbedrer forbedringsområder innenfor sikkerhetsstyringssystemet.

Sikkerhet skal ha høyeste prioritet i militære operasjoner i fredstid. Samtidig løser Marinen oppdrag som
impliserer risiko og har målsetting om realistisk trening for krise og krig. Vi har derfor behov for en
velutviklet sikkerhetskultur slik at medarbeidere på alle nivå evner å balansere operativ risiko og
sikkerhet i operasjoner. Ulykken har aktualisert behovet for å kontinuerlig arbeide med de kulturelle
forutsetningene for sikkerhet i Marinen.
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Umiddelbart etter ulykken ga jeg føringer om å utvise aktsomhet og legge inn ekstra marginer inntil
årsaksforholdene var kartlagt. Dette er kommunisert til alle skipssjefer i Marinen skriftlig og i en rekke
samlinger vi har hatt. Vi har gjennom året tilrettelagt for gode diskusjoner mellom alle skipssjefer for å
utveksle erfaringer og harmonisere praksis. Rapportering på sikkerhet har fått en styrket posisjon på
agendaen i ledermøter og risikovurderinger har fått en større plass i planlegging av kommende
operasjoner og øvelser. Ledelsens oppfølging av dette vil vedvare.
Sjøforsvarets sikkerhetspolicy er dekkende for alle deler av virksomheten. For å kunne gi føringer som er
mer konkret rettet mot Marinens virksomhet vil det utarbeides en sikkerhetspolicy spesifikt for Marinen.
Kurs og utdanningsopplegg skal gjennomgås for å sikre at sikkerhet og dilemmatrening blir en integrert
del av all kompetansebygging. Arbeid med sikkerhetskultur er et langsiktig arbeid. Den interne
undersøkelsesgruppen har gjennomført en studie av sikkerhetskultur med støtte av DnVGL som viser at
sikkerhetskulturen på flere områder er god, men også pekt på tydelige forbedringspotensial. Nye studier
av samme type de kommende år vil danne grunnlag for å måle progresjon.

Umiddelbart etter hendelsen ble det innført to strakstiltak relatert til navigasjon på Marinens fartøyer.
Retningslinjene for bruk av AIS ble presisert og det ble innført en ekstra sikkerhetsbarriere i forbindelse
med opplæringsaktiviteter for navigatører. For en mer bred og gjennomgang og varig styrking av
fagområdet navigasjon har jeg etablert «Prosjekt Navigatøren». Arbeidet ledes av Sjøforsvarets
Navigasjonskompetansesenter (NAVKOMP) og deres mandat er vedlagt. Hensikten er å utrede og
implementere tiltak raskt og effektivt innenfor hovedområdene regelverk, kompetanse og
erfaringslæring. Å sikre at «best practice» på enkelte fartøystyper gjøres gjeldende for alle vil være et
sentralt mål, herunder å sikre at vi har rett erfaringsnivå og klareringskriterier for alle navigatører og
broteam. Evnen til effektiv samhandling i broteamene på alle Marinens fartøyer tillegges vekt i dette
arbeidet, herunder implementering av en mer systematisk trening i «Crew Resource Management».

Marinen opererer avanserte fartøyer med komplekse systemer og har derfor et omfattende system for
dokumentasjon av instrukser, prosedyrer og rutiner. Disse inngår i et større dokumenthierarki med felles
bestemmelser for Forsvaret, Sjøforsvaret og Marinen, samt teknisk dokumentasjon fra FMA MARKAP.
Fregattenes dokumentasjon ble sist oppdatert i 2016. Første halvår 2019 har det vært gjennomført en
større revisjon av fregattenes interndokumentasjon som vil bli sluttført medio september.
I lys av hendelsen med Helge Ingstad vil det nå bli iverksatt en revisjon av hele dokumenthierarkiet for
alle Marinens fartøyer for å sikre at dette er oppdatert, harmonisert, forenklet og lett tilgjengelig. Dette
vil også styrke vår evne til å gjøre kontinuerlige oppdateringer basert på erfaringer. En hovedmålsetting
er å sikre større grad av felles retningslinjer på tvers av fartøystypene. Arbeidet er omfattende og favner
alle faginstanser i Marinen samt en rekke eksterne instanser, og vil bli organisert som et prosjekt med
prioritet på dokumentasjon som er relatert til operasjonell og teknisk sikkerhet, herunder navigasjon,
sjømannskap, brann og havari, samt sanitet.

En forutsetning for sikker drift av marinens fartøy er at personellet innehar rett kompetanse og at avvik i
forhold til kompetansekrav blir identifisert, risikovurdert og nødvendige tiltak iverksatt. Marinen har i
første halvår 2019 gjennomgått gjeldende kompetansekrav og verifisert personellets faktiske
kompetanse. Kompetansekrav omfatter kvalifikasjoner, erfaring, kurs, utdanninger og klareringer.
Videre er Marinens kurs gjennomgått, kontrollert og blir nå registrert i den enkeltes rulleblad.
Kodifisering av erfaringsnivå innenfor de spesifikke funksjoner er utarbeidet og implementert i
Forsvarets felles kompetansestyringsverktøy. I tiden fremover vil det være behov for å kvalitetssikre
datagrunnlaget som er etablert og etterregistrere all sjømilitær kompetanse på den enkelte
medarbeideren.
Dette grunnlagsarbeidet vil vi benytte til å styrke våre rutiner og verktøy for monitoriering og
rapportering av den enkeltes og fartøyets kompetanse, med vekt på å kunne identifisere avvik. Det vil bli
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vurdert justeringer av både prosesser og organisering av Sjøforsvarets HR-apparat for å sikre en

tydeligere involvering i driften av Marinens fartøyer.

Teknisk sikkerhet avhenger av leveranser fra flere aktører i og utenfor Forsvarssektoren. FMA MARKAP
er ansvarlig for fartøyenes tekniske sikkerhet og sertifisering. Fregattene er klasset av DnV-GL.
Forsvarets Logistikkorganisasjon utfører tyngre vedlikehold. Marinen legger det økonomiske premisset
for vedlikehold og det er avgjørende med gode samhandlingsprosesser med aktørene slik at riktige
prioriteter blir gitt.
FMA MARKAP har i etterkant av Ingstad-havariet gjennomgått den tekniske sikkerheten for fregattene
og oppgir følgende tiltak som gjennomført:
- Det er gjennomført en intern teknisk undersøkelse i FMA MARKAP med flere funn som er under
saksbehandling.
- Det ble umiddelbart etter varsling om manglende vanntett integritet (hul aksling) mellom aktre
generatorrom og girrom gjennomført midlertidig tiltak for å opprette vanntett skille mellom de to
rommene. Det er nå gjennomført en varig reparasjon på de fire gjenværende fartøyene og saken er
lukket.
- Det er gjennomført ny krengeprøve på KNM Fridtjof Nansen som har verifisert dataene for
stabiliteten på fregattene og de gitte anbefalingene hva gjelder handling ved skadet skrog. Det er
ikke avdekket feil i stabilitetshåndboken og den har ikke avvik fra klasse
- Vedlikeholdsrutinen for lensesystemet er oppdatert for å verifisere at dette er funksjonsdyktig.
- Det er utgitt en presisering av konfigurasjon på hovedtavler for å redusere risiko for å miste
strømforsyningen om bord (svart skip).
- Det er utgitt nye prosedyrer for operering av navigasjonslanterner som skal motvirke at de slukker
hvis fartøyet får svart skip.

Sjef FMA MARKAP har utstedt flere Materiellsikkerhetspåbud (MSP) som ivaretar sikkerhetskritiske
avvik. Fra Marinens side er det etablert rutiner slik at en oversikt over alle gjeldende påbud relatert til
materiellsikkerhet sendes fartøyene regelmessig. I tiden fremover vil vi i samarbeid med FMA MARKAP
arbeide med å styrke den helhetlige oversikten og prioriteringen av tekniske avvik og oppfølgingen av
teknisk sikkerhet.
Sjef FMA MARKAP har etter ulykken satt ned et prosjekt for å gjennomgå materiellforvaltningen spesielt
relatert til fregattene. Sentrale elementer i dette prosjektet er:
- Konfigurasjonskontroll og endringsbehandling
- Avviksbehandling og kontroll
- Oppdatering av teknisk dokumentasjon
- Oppdatering av fartøyenes vedlikeholdssystem og reservedelsforvaltning

Marinen har etablerte rutiner for rapportering og behandling av avviksrapporter. Rapporteringskulturen

anses på de fleste områder for å være relativt god og skal danne grunnlag for organisatorisk læring ved å
iverksette tiltak. Avvikshåndteringen på alle områder har siden ulykken fått økt ledelsesfokus ved at
kritiske avvik relatert til HMS og teknisk sikkerhet skal rapporteres uten opphold til ledelsen for å sikre
riktige prioriteringer. Status gjennomgås rutinemessig på ledermøter.
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Rapportering av erfaringer og nesten-uhell innenfor navigasjonshendelser har vært for svak og det ble i
2017 tatt grep for å bedre dette, men det er fortsatt behov for bedring. Avviksrapportering av
navigasjonshendelser vil nå bli fulgt grundig opp i rammen av «Prosjekt Navigatøren» hvor vi skal ha på
plass bedre insentiver og en styrket læringssløyfe.
I tiden fremover vil vi styrke feed-back sløyfen. Relevante erfaringer innenfor navigasjon skal samles,
redigeres og publiseres av NAVKOMP. Opprydning i dokumenthierarkiet vil legge til rette for mer
effektiv oppdatering av rutiner og deling av «best practice» basert på erfaringer.

Marinen har driftsansvaret for egne fartøyer, men noen av forutsetningene for sikker drift hviler også på
systemer og verktøy som er felles for hele forsvarssektoren, og samhandling med andre etater, i
særdeleshet Forsvarsmateriell. Behov for endringer på overordnede systemer og forholdet til eksterne
er adressert av Sjøforsvarsstaben (SST), men myndighet til å gjøre endringer ligger utenfor Sjøforsvaret.
SST har identifisert mangler relatert til IKT-verktøy for understøttelse av sikker drift av vår maritime
virksomhet. Funksjonalitet og tilpasning av proprietære systemer er ikke optimalisert for kontroll på
avvikshåndtering, risikovurderinger, kompetansestyring og dokumentasjonsstyring av en maritimt rettet
virksomhet. Sjøforsvaret har anmodet Forsvarsstaben om å kartlegge behov for- og anskaffe tilpassede
verktøy som vil gi avdelinger og fartøyer tilfredsstillende funksjonalitet og kapasitet til å ivareta sikker
drift i henhold til gjeldende krav i lovverket.
Utover dette har Sjøforsvaret anmodet Forsvarsdepartementet (FD) om å klargjøre roller, ansvar og
myndighet ift skipssikkerhetsloven med tilhørende forskrifter. Dette er iverksatt av FD og aktuelle etater
er involvert og støtter arbeidet.
På teknisk side ble de umiddelbare vurderingene gjort av FMA MARKAP som beskrevet over, og tiltak
implementert. For å sikre en grundig gjennomgang av alle mulige avvik på tekniske systemer har SST
derfor bedt FMA MARKAP om en teknisk granskning av valgte løsninger i forhold til gjeldende regelverk,
teknisk dokumentasjon, operasjonsmanualer samt en gjennomgang av løsningene om bord på
fregattene. Formålet er å sikre at systemene på de gjenværende fartøyene er i samsvar med
spesifikasjoner og gjeldende regelverk.

Marinen, Sjøforsvaret og FMA MARKAP har etter kollisjonen mellom KNM Helge Ingstad og Sola TS
iverksatt en rekke tiltak for å bedre sikkerheten på Marinens fartøyer. Arbeidet er over i en mer
systematisk fase for å sikre varig styrking av sikkerhetsnivået og har høyeste prioritet i hele
organisasjonen. Vi tilstreber å gjennomføre tiltak som gir varige effekter og konkrete resultater, både
innen grunnleggende sikkerhetsaspekter og fra et ledelsesperspektiv. Arbeidet skal bygge videre på vårt
system for trening, øving og kvalitetssikring av sikkerhetsnivået, men også en forståelse for at den
alvorlige hendelsen avdekker forhold som kan ta oss et vesentlig skritt videre. Arbeidet som allerede er
iverksatt skal forberede oss på omsette de funn og anbefalinger som fremkommer av rapportene fra
Statens Havarikommisjon og Sjøforsvarets interne undersøkelse.

Rune Andersen
Flaggkommandør
Sjef Marinen
Accident Investigation Board Norway Appendix H

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 Accident Investigation Board Norway Appendix H

AIBN’s translation of Appendix H

Status report from the Fleet to the Accident Investigation Board Norway
1 Introduction
Reference is made to the collision between ‘KNM Helge Ingstad’ and ‘Sola TS’ on 8 November 2018
and the report that is soon to be released by the Accident Investigation Board Norway (AIBN). The
purpose of this communication is to describe the status with respect to measures that have been
implemented in the wake of the accident, and the ongoing effort to ensure lasting and better safety
for our vessels and crews.
We have implemented measures in areas where weaknesses have been identified, and have now
entered a phase of systematically working to identify areas for improvement and ensuring a higher
safety level on a lasting basis. The upcoming reports from the AIBN, the internal investigation
initiated by the Chief of the Royal Norwegian Navy and the technical investigation by the Norwegian
Defence Material Agency’s Naval Systems Division (FMA MARKAP) will constitute important
contributions to our efforts. Pending the above reports, the Fleet has chosen to focus on safety
culture, navigation, technical safety, documentation, competence management and handling of
nonconformities. The dialogue with competent authorities to map and improve the overall
framework conditions for safety is being handled by the Naval Staff, including the clarification of
roles, responsibility and authority relating to the Ship Safety and Security Act and its regulations.
The Navy has a cooperation agreement with the Chief of FMA MARKAP under which FMA MARKAP is
responsible for technical safety pursuant to the Ship Safety and Security Act and its regulations.
As far as the Fleet is concerned, our work in the time ahead will be based on the Fleet’s current
strengths in the safety area, with the emphasis on systematic training and certification of vessels and
selection of personnel to positions critical to safety, while at the same time being realistic and self-
critical in the way we identify and make improvements where there is a potential for improvement in
our safety management system.

2 Safety culture
Safety shall have the highest priority in military operations in times of peace. At the same time, the
Fleet carries out assignments that entail risk and aims to provide realistic training for situations of
crisis and war. We therefore need a well-developed safety culture so that staff at all levels are able to
strike a balance between operative risk and safe operation. The accident has highlighted the need to
continuously address the cultural conditions for safety in the Fleet.
Immediately after the accident, I issued guidance on exercising vigilance and operating with
additional margins until the causal factors were identified. This has been communicated to all
captains on board the Fleet’s vessels, both in writing and at a number of gatherings. Throughout the
year, we have facilitated good discussions between all captains of our vessels for the purpose of
exchanging experience and harmonising practice. Safety reporting has been given a more prominent
position on the agenda at management meetings and more time is spent on risk assessments when
planning upcoming operations and exercises. Management will continue to follow up these matters.
The Navy’s safety policy applies to all parts of the Navy’s activities. In order to provide more
particular guidance for the activities of the Fleet, a safety policy will be prepared specifically for the
Fleet. Courses and educational schemes will be reviewed to ensure that safety and dilemma training
become an integral part of all competence-building. Establishing a safety culture is long-term work.
Supported by DnVGL, the internal investigation team has carried out a study of the safety culture,
which shows that, while the safety culture is good in several areas, there is clearly improvement
potential in others. Repeating studies of this type in the years ahead will enable us to measure what
progress we make.

1
 Accident Investigation Board Norway Appendix H

3 Navigation
Immediately after the incident, two immediate measures were introduced relating to navigation of
the Fleet’s vessels. The guidelines for use of AIS were clarified and an additional barrier was
introduced in connection with training activities for navigators. I have established a navigator project
(Prosjekt Navigatøren) to ensure a broader review and strengthen the navigation discipline on a
lasting basis. The project is headed by the Navy’s Navigation Competence Centre (NavKomp), whose
mandate I have enclosed. The purpose is to elaborate on and implement measures quickly and
effectively in the primary areas regulations, competence and experiential learning. A key goal will be
to ensure that best practice on certain vessel types is made generally applicable, including that all
navigators and bridge teams have the requisite level of experience and are subject to the right
clearance criteria. This work focuses on the ability of all bridge teams on the Fleet’s vessels to
cooperate effectively, and includes the implementation of systematic training in crew resource
management.

4 Documentation
The Fleet operates state of the art vessels with complex systems and therefore has a comprehensive
system for documentation of instructions, procedures and routines. These are part of a document
hierarchy containing common provisions for the Norwegian Armed Forces, the Navy and the Fleet, as
well as technical documentation from FMA MARKAP. The frigate documentation was most recently
updated in 2016. A major revision of the frigates’ internal documentation has been carried out
during the first half of 2019 and will be completed in mid-September.
In light of the incident with ‘KNM Helge Ingstad’, a revision will be conducted of the document
hierarchy for all the Fleet’s vessels as a whole, to ensure that it is updated, harmonised, simplified
and easily accessible. This will also strengthen our ability to introduce continuous updates on the
basis of experience. It is a main objective to ensure more common guidelines across the different
vessel types. This is an extensive task and involves all professional bodies in the Fleet as well as a
number of external bodies; it will be organised as a project giving priority to documentation relating
to operational and technical safety, including navigation, seamanship, fire and accidents, and the
medical service.

5 Competence management
The safe operation of naval vessels depends on crews having the right competence and on
identifying any nonconformities relating to competence requirements, conducting risk assessments
and implementing necessary measures. During the first half of 2019, the Fleet has reviewed current
competence requirements and verified the actual competence of personnel. Competence
requirements include requirements for qualifications, experience, courses, education and clearances.
Furthermore, the Fleet’s courses have been reviewed and records are now kept for each employee.
The level of experience relating to specific functions has now been codified and incorporated in the
Armed Forces’ common competence management tool. In the time ahead, we need to quality-assure
the established data basis and register all the naval competence of individual employees.
We will use this fundamental work to strengthen our procedures and tools for monitoring and
reporting the competence of individuals and vessels, with the emphasis on being able to identify
nonconformities. Consideration will be given to adjusting both processes and the Navy’s HR
administration, in order to ensure clearer involvement in the operation of the Fleet’s vessels.

6 Technical safety
Technical safety depends on deliveries from several parties, both inside and outside the defence
sector. FMA MARKAP is responsible for the technical safety and certification of our vessels. DnV-GL is
responsible for the classification of the frigates. Heavy maintenance is carried out by the Norwegian
Defence Logistics Organisation. The Fleet sets the financial premises for maintenance, and good
processes for cooperation with the parties involved are decisive for making the right priorities.

2
 Accident Investigation Board Norway Appendix H

Following the accident with ‘KNM Helge Ingstad’, FMA MARKAP has reviewed the technical safety of
the frigates and reports that the following measures have been implemented:
- An internal technical investigation has been conducted by FMA MARKAP, resulting in several
findings that are now being processed.
- Immediately after the lack of watertight integrity (hollow axle) between the aft generator room
and the gear room had been reported, temporary measures were implemented to establish a
watertight division between the two compartments. Permanent repairs have now been carried
out on the four remaining vessels, and the case has been closed.
- A new inclining test has been carried out on ‘KNM Fridtjof Nansen’, verifying the stability data of
the frigates and the recommended handling of the vessels in connection with hull damage. No
errors have been found in the stability handbook and it contains no nonconformities related to
the class of vessel.
- The bilge system maintenance procedure has been updated for the purpose of verifying that it is
in working order.
- A more precise description has been issued of the main switchboard configurations on board, in
order to reduce the risk of loss of power (blackout).
- New procedures have been issued for operating the navigation lights to prevent them from being
extinguished in the event of a blackout.

The head of FMA MARKAP has issued several safety orders relating to materiel
(Materiellsikkerhetspåbud – MSP) addressing safety-critical nonconformities. The Fleet has established
procedures whereby the vessels regularly receive an overview of all MSP orders. In the time ahead, we
will collaborate with FMA MARKAP to improve our overview and prioritisation of technical
nonconformities and strengthen our follow-up of technical safety.
After the accident, the head of FMA MARKAP has initiated a project to review materiel management,
particularly of the frigates. Key elements of this project include:
- Configuration control and change management
- Handling and control of nonconformities
- Updating technical documentation
- Updating the vessels’ maintenance systems and spare parts management

7 Handling of nonconformities
The Fleet has procedures in place for reporting nonconformities and handling nonconformity reports.
The reporting culture is considered to be fairly good in most areas, and is meant to form the basis for
organisational learning through the implementation of measures. Since the accident, there has been
more management focus on nonconformity reporting in all areas in that critical nonconformities
relating to HSE and technical safety are to be reported to management without delay to ensure
correct prioritisation. Status is reviewed at management meetings as a matter of routine.
There is still some under-reporting relating to incidents and near-misses in the area of navigation,
and even though measures were taken to improve this in 2017, there is still a need for improvement.
Nonconformity reporting of navigation incidents will now be followed up thoroughly within the
framework of the navigator project (Prosjekt Navigatøren), which aims to establish better incentives
and a stronger learning loop.
In the time ahead, we aim to strengthen the feedback loop. Relevant empirical experience of
navigation shall be collected, edited and published by NAVKOMP. Tidying up the document hierarchy
will facilitate more effective updating of procedures and sharing of best practice on the basis of
experience.

3
 Accident Investigation Board Norway Appendix H

8 Measures implemented by the Naval Staff

The Fleet is responsible for the operation of its own vessels, but some of the conditions for safe
operation also depend on systems and tools that are common to the whole defence sector, as well as
on cooperation with other public agencies, particularly the Norwegian Defence Materiel Agency. The
need for changes to governing systems and the relationship with external parties have been
addressed by the Naval Staff, but the authority to make changes lies elsewhere. The Naval Staff has
identified shortcomings relating to ICT tools for supporting the safe operation of our maritime
activities. The functionality and adaptation of proprietary systems have not been optimised for
control of the handling of nonconformities, risk assessments, competence management and
document control in a maritime undertaking. The Navy has requested the Naval Staff to map the
need for and procure suitable tools that will provide departments and vessels with satisfactory
functionality and the capacity to ensure safe operation in accordance with applicable statutory
requirements.
In addition to this, the Navy has requested that the Ministry of Defence clarify roles, responsibility
and authority in relation to the Ship Safety and Security Act and its regulations. The Ministry of
Defence has acted on this and relevant public agencies are involved in and support the work.
On the technical side, the immediate assessments were carried out by FMA MARKAP as described
above, and measures were implemented. In order to ensure a thorough review of all possible
nonconformities in the technical systems, the Naval Staff has therefore asked FMA MARKAP to
conduct a technical investigation of the chosen solutions in relation to applicable regulations,
technical documentation and operating manuals, as well as a review of the solutions on board the
frigates. The purpose is to ensure that the systems on the remaining vessels are in accordance with
the specifications and applicable regulations.

9 Conclusion
After the collision between ‘KNM Helge Ingstad’ and ‘Sola TS’, the Fleet, the Navy and FMA MARKAP
have implemented a number of measures to improve safety on board the Fleet’s vessels. The work
has entered a more systematic phase to ensure a lasting heightening of the safety level and is given
top priority throughout the organisation. We seek to implement measures that will have lasting
effect and give concrete results, both in terms of basic safety aspects and from a management
perspective. This work will be a further development of our system for training, exercises and quality
assurance of the safety level, but will also be based on an understanding of the serious incident
having brought to light circumstances that enable us to take a material step forward. The work that
has been done already will prepare us for the findings and recommendations made in the AIBN’s
reports and the Navy’s internal investigation report.