9 April 2019
The vessel was under 10 years old, fitted with a suite of navigational instruments not usually found on a merchant ship and the master and crew had a wealth of experience and qualifications from well-respected administrations. Nevertheless, the vessel grounded, close to shore, off a remote nature reserve – the consequences could have been catastrophic but thankfully were not.
Interviews with the bridge team and analysis of evidence including the navigation systems, passage plans and voyage data recorder highlighted that a failure of the bridge team’s culture was the overriding factor that caused the incident.
The culture failed in three distinct ways - a failure to plan, ingrained complacency in the senior officers and a huge power distance between the master and his navigators that inevitably meant the first two failures could not be challenged.
Firstly, let’s talk about planning: the vessel was essentially involved in two distinct operations – navigating close to shore and the recovery of tenders. Those in the offshore or hydrocarbon sectors will recognise this as Simultaneous Operations (SimOps) i.e. when two or more potentially conflicting activities are being executed in the same location at the same time. Generally, SimOps require a risk assessment with input from personnel involved in each operation to ensure all hazards are assessed and effective control measures are implemented to cover the whole operation. In this instance the SimOps risk assessment would have been a combination of existing risk assessments combined and re-assessed with the passage plan, involvement for all parties could have taken the form of a bridge briefing with environmental factors for boat recovery overlaid on to the requirements for safe navigation and the resulting control measure would have been an operating envelope that was clearly defined and that could be effectively monitored. Positive reporting would have kept everyone in the loop, unfortunately however that is not what happened.
In this particular grounding incident, there was no passage plan covering this element of the voyage, the risks around boat recovery were considered as a standalone operation and those responsible for each element did so with no central oversight or effective monitoring. More on how this happened later.
The complacency in the senior ranks was clearly apparent during interviews and evidenced through the master’s approach to navigation near to shore in an area charted with the existence of overfalls, eddies and breakers and identifiable as an unassessed Category Zone of Confidence on the ship’s ECDIS. The vessel’s master was not making use of the resources available – he did not use the dynamic positioning systems as he considered himself an excellent ship handler and consequently the ECDIS was not utilised as he favoured paper charts.
Despite this confidence, the vessel drifted in to danger and her position was not adequately monitored. At no point during the 30 minutes prior to the grounding, was the vessel’s position fixed, did the master request any information from the Officer of the Watch nor did the OOW proactively offer any navigational advice.
That brings us to power distance which, in simplified terms, could be expressed as the extent to which a junior team member will accept the senior team member’s authority without question. Power distance is influenced by multiple factors (such as culture and/or nationality – see the power distance index by country) and is something that needs to be properly managed to ensure an effective bridge team. In this instance the master thought he was incapable of error and the junior officer knew there should be a plan in place and that the master’s approach was not in line with good BRM principals – however the overriding culture meant she felt she could not raise her concerns or question his approach.
This relatively benign incident highlights that additional resources are pointless unless effectively utilised, that bridge resource management relies on a culture where challenge is welcomed and respected regardless of who is challenging whom and finally, the old adage that if you fail to plan, you must plan to fail.
BMT’s surveys team provide investigation services post-incident but also pre-risk navigation assessments, working with operators, charterers and P&I Clubs to improve bridge team performance and identify and reduce navigational risk.
Nick Dowden is our Marine Surveyor/Surveys Team located in the London Office.
For more information please go to: Navigation assessments
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