Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
M2246
Initial Report
A reporter recounted an incident to CHIRP involving a grounding that resulted in the loss of jobs for the reporter and another officer. The incident caused minor damage to the vessel’s hull bottom but no physical injuries. Contributing factors were distractions and poor preparation.
On the day of departure, the master was preoccupied with obtaining a crew visa and addressing engineering problems. Due to the visa requirements, the vessel was already a few days late setting sail for the 10-day passage to return to its home port. Despite these challenges, the passage plan was completed by mid-afternoon. However, a critical issue arose with the primary ECDIS system, displaying incorrect charts for the planned route. Despite this, the decision was made to depart using information from other sources, including paper charts and a secondary ECDIS display, and knowing there would be a pilot onboard.
During the vessel’s unmooring, the pilot’s apparent distraction with their phone hindered communication and coordination. Despite the very brief master pilot exchange for the outbound passage, there appeared to be no overall control over the vessel’s navigation. Concerning the pilot’s action, there was a lack of appropriate response and communication to some basic navigational queries, including the buoyage, during which time the vessel strayed off course. The master’s intervention to get the vessel back on the track came too late to avert the grounding.
Following the grounding, the crew responded promptly and effectively. Efforts to refloat the vessel at the next high water were successful, with minimal damage sustained. Subsequent inspections found no significant damage to the vessel’s structure or running gear after an underwater inspection was carried out in accordance with the port authority’s requirements.
CHIRP Comment
This grounding incident stemmed from a series of human factors issues, indicating a breakdown in navigational procedures and communication on the vessel.
Upon arriving at the bridge, both the master and the pilot were distracted, compromising their ability to focus on safely navigating the vessel. This distraction likely contributed to a lack of thorough understanding and discussion of the passage plan, which had only been completed shortly before departure. As a result, there was insufficient time for the master and other officers to assess and approve the plan properly.
Responsibility on the bridge was diffuse, leading to no action or delays in decision-making and a failure to take necessary actions to correct deviations from the passage plan. Furthermore, the inability of instrumentation alarms, specifically the ECDIS and echo sounder, to activate when the vessel deviated off track and entered shallow waters suggests potential technical failures or improper setup of these systems.
Despite having alternative navigation systems, such as paper charts and another ECDIS system, there was no evidence that these were utilised to verify deviations from the passage plan. This highlights a missed opportunity to cross-reference information and mitigate the risk of navigational errors.
Overall, this incident underscores the importance of effective communication, thorough planning, crew training, and the proper functioning of onboard systems in ensuring safe navigation at sea.
Key Issues relating to this report
Distractions – Too many issues affected the master during this very hectic departure, and insufficient attention was given to the vessel’s navigation. The pilot was also distracted with phone calls and did not assist the bridge team with adequate navigational information.
Teamwork —Bridge teamwork was dysfunctional, creating an unsafe condition for navigation. The vessel was left with no overall control until the grounding. Applying for a visa should be delegated to another member of the officer complement or the ship’s agent.
Pressure—Commercial pressure to return the vessel to its home port created unnecessary stress for the master. Visa issues, engineering problems, and bridge navigation issues were compounded by a pilot who appeared detached from the job he was employed to perform.