Part 1 - Merchant Vessels - Marine Accident Investigation Branch

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Inexperience and a Lack of Communication - a Dangerous Mix Narrative A relief master was in command of a ro-ro ferry operating between two regular ports of call. It was a calm, clear night, the tide was just beginning to flood, and once loading was completed the vessel departed the berth for a night crossing. The bridge was well equipped but the other officers were temporary personnel. There was no pre-departure briefing and almost no information flow between the officers once the vessel was underway. Shortly after departure, the master became distracted by the remote tidal gauge display which was showing below prediction, and by the echo sounder which was operating intermittently. During this time he was also attempting to negotiate a bend in the channel. He took the turn too wide, and the vessel grounded on the opposite bank. Neither the chief officer nor the second officer warned the master that the vessel was straying into danger. Lookout Bridge team MAIB Safety Digest 1/2012 Master CASE 8 For the next 45 minutes the master tried to manoeuvre the vessel free. During this time he did not notify the coastguard, harbour authority or his company that the vessel was aground, nor did he inform the passengers or the engine room. Nobody on the bridge consulted the post-grounding checklist. The chief engineer (also a relief) became aware that the ship was aground, but he did not want to disturb the master and did not contact the bridge. Although he took some precautions, the chief engineer also failed to consult the checklists, and no one checked to see if the vessel was taking on water. Fortunately the vessel floated free on a rising tide without sustaining any damage, and she continued on passage. No checks of the propulsion or steering gear were made and the incident was still not reported. Some shore workers, however, had seen the vessel stationary in the channel, and the incident was brought to the attention of the DPA the following day. Mate Boatswain 2nd mate 27
CASE 8 The Lessons 1. A good bridge team would have identified that the vessel was taking the turn wide and was at risk of grounding, and would have told the master in good time. 2. A bridge team needs to know the master’s intentions if they are to monitor his actions effectively. This is achieved by a good predeparture briefing and a commentary from the master during the passage. 3. It is important that the coastguard and harbour authority are made aware of any incident as soon as possible – even if no assistance is required. They can then monitor the situation and be ready to assist should the incident deteriorate. 4. Had a more experienced team been on board that night it is likely that some, if not all, of the post-grounding actions and reports might have been carried out. 28 MAIB Safety Digest 1/2012
Page 1 and 2: Part 1 - Merchant Vessels ‘Keep i
Page 3 and 4: CASE 1 Heavy Weather - Serious Inju
Page 5 and 6: CASE 1 The Lessons 1. When the ship
Page 7 and 8: CASE 2 Figure 2: Hold ventilation c
Page 9 and 10: CASE 4 Lift Shaft Working Can Kill
Page 11 and 12: CASE 4 The Lessons 1. Lack of plann
Page 13 and 14: CASE 5 Figure 2: CPP command signal
Page 15 and 16: CASE 5 The Lessons Luckily, the out
Page 17 and 18: CASE 6 They immediately pushed the
Page 19: CASE 7 The Lessons 1. The cause and
Page 23 and 24: CASE 9 The planned tracks of the ve
Page 25 and 26: CASE 10 Figure 2: Pipe securing arr
Page 27 and 28: CASE 11 Watch ‘Sleeping’ Leads
Page 29 and 30: CASE 13 Watch Your Step Narrative M
Page 31 and 32: CASE 13 The Lessons This was a simp
Page 33 and 34: CASE 14 Figure 1: AIS data Position
Page 35 and 36: CASE 15 Navigating the Cut Narrativ
Page 37 and 38: CASE 16 Is the Forward Store a Dang

Part 1 - Merchant Vessels - Marine Accident Investigation Branch

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