Fleet Management Limited

Operational Information

No. 2/01

7th March 2001

Don't let this happen on your ship!

Bridge Team Failure

The Incident
1.	Vessel was departing port in the early hours of the morning. Master and 2nd officer were on the Bridge and an A/B was at the wheel.

2.	The Channel was about 1.5 miles wide with islands on both sides and deep water till very close to the shore line.

3.	At about 0210 hrs Pilot disembarked 5' prior to the scheduled disembarking point. At this time there was one ship headed in to port on reciprocal course with pilot onboard. 2nd Officer accompanied the Pilot down to see him off. This left the Master and the A/B on the Bridge.

4.	Course to steer was 127 x 2.5' followed by 105 x 3.5' leading to open sea.

5.	While disembarking, the Pilot asked Master to alter course to starboard to keep clear of the incoming vessel and the vessel altered to 142 deg. A few minutes later course was further altered to 145 deg by the Master as the Pilot called from the deck asking Master to do so.

6.	The vessel is fitted with a Central Navigation Console which houses all navigational equipment. There are two ARPA radars on either side of the wheel.

7.	The 2nd officer returned to the Bridge at about 0215. He stood in front of the port radar to the left side of the A/B who was at the wheel. He noted that vessel was steering 145, Engines were on Full Ahead and speed was about 15 knots. He also observed the Master on the phone standing only a few feet away to the right side of the A/B informing engine room to increase to sea speed. At this time he asked the Master if he should alter to Port. Master did not reply. 2nd Officer presumed that Master had detected some other target and was hence delaying the alteration. 2nd officer then looked at the Starboard Radar and did not see any other target, he again asked Master if he should alter to Port. Master did not reply, instead he picked up the telephone and started talking to a shore technician who was sailing onboard. 2nd Officer then went to the chart room and plotted the position which showed that vessel was headed straight for an island which was only 7 cables away. He saw Master still on the phone and again asked Master shall I alter to Port. Master looked up and said yes. 2nd officer ordered port 5 on the helm. Master then looked at the radar saw the danger and shouted hard port. Helm was given but it was too late and a few seconds later at 0223 there was a loud thud and vessel's speed dropped from 15 knots to zero.

8.	Vessel was found to be firmly on the rocks in way of forepeak tank and No.1 DB. Subsequently with help of tugs vessel was re-floated and proceed to port.

Cause of the Incident
1.
Failure to maintain an effective navigational watch.

2.
Poor communication between Master and the 2nd Officer.

3.
Master was preoccupied with less important matters and was also on the phone twice for long periods. He was not aware of the situation on the Bridge and completely neglected his primary responsibilities.

4.
Master and 2nd officer did not fully appreciate scale of the chart in use and they seemed to think that there was more sea room than actually was the case.

5.
High speed of the vessel meant that there was little time for corrective action.

6.
After plotting the position and realising that vessel was in imminent danger, 2nd Officer should have taken immediate action or shouted out loudly from chart room to alert Master of the Danger.

7.
Action of 5 deg port helm by 2nd Officer was also insufficient under the circumstances.

Lessons to be learnt
1.
A proper and effective Navigational watch is to be maintained at all times.

2.
Staff who are on watch keeping duties shall not perform such tasks which may divert or distract their attention.

3.
Conversation on telephone, VHF, Inmarsat phone calls etc shall be very brief and to the point.

4.
If Master receives an Inmarsat or Mobile telephone call while navigating, he must inform the caller that he is busy with navigation and will call back later.

5.
There must be clear understanding between Master and all navigational watch keepers as to procedures to be followed so that the junior officer can alert Master of requirements / dangers / hazards without the fear of acting beyond his authority.

6.
The presence of the Master on the bridge does not absolve the navigating watch keeping officer from his responsibility and obligation to take corrective action in the face of imminent danger even if the Master is in command and for some reason has failed to realise the gravity of the situation.

7.
The Passage Plan is to be discussed by the Master and navigational watch keepers and clear understanding of intended track and procedures by all staff is to be ensured.

8.
Practice of duty officer going down to receive / send off the pilot is not good as the officer is disoriented when he returns and takes a few minutes to regain the full picture. During this period Master is the sole lookout and watch officer. This task of receiving / seeing off Pilot is to be assigned to an officer who is not on watch at the time or an additional lookout should be on the Bridge to assist Master if Duty officer is leaving the Bridge.

9.
As far as possible, Pilot should be disembarked at the designated position instead of letting him go early even if the passage appears clear.

10.
Visitors and off duty personnel shall not be permitted on the bridge.

"Be Alert on the Bridge Work as a Team!!"