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January 25, 2014

Voyager News

Why shallow waters mean deep trouble

Human error, fatigue, complacency, deviation from the passage plan, poor risk assessment or management of bridge resources. All have been contributory factors in high profile grounding incidents. All are put under the spotlight in a new film, GROUNDINGS: Shallow Waters, Deep Trouble, released by the Steamship Mutual P&I Club.

The film considers the causes and effects of some high profile casualties, including the Sheng Neng 1, Rena, Fedra and others, in an attempt to highlight the threats to safety that can occur on a modern bridge. In these cases, there was no loss of life, but the impact in pollution, environmental damage and the bill for wreck removal and clean-up is clearly a cause for concern to the insurance community.

Chris Adams, Head of Loss Prevention for the Club’s Managers, says the catalyst for the film was recent claims experience which highlighted both the frequency and severity of grounding incidents as compared with other categories of major loss.

“The primary intended audience is Masters and deck officers. By using case studies of actual occurrences in which there have been really quite simple failures, and catastrophic consequences, the expectation is that that it will provide food for thought and hopefully encourage improved practice,” he says.

What the film illustrates is how often such casualties stem from minor errors which combine to form a chain that inevitably lead to accidents.

In one situation, commercial pressure caused a Master to make unsafe decisions and which he knows are wrong but proceeds nonetheless. This is despite the Master having authority under the ISM Code, which should give him the full backing of the shore management team.

As the film points out, an open, healthy and transparent master-superintendent relationship is key to a safe ship. Mr Adams says superintendents should be encouraged to regularly visit the ships they are running, building a relationship with the vessel team, as well as ensuring the ship is being operated in compliance with international regulations and company procedures.

“The Master has overriding authority to take decisions he feels are necessary in the interests of the safety of his ship and crew,” he says. “Masters need to be have the confidence to take such decisions and in this respect it is imperative that they receive support and backing of the DPA and shore management.”

When the cruiseship Sea Diamond capsized and sank after striking a rock off Santorini, potentially huge loss of life was thankfully averted, although there were two fatalities. Investigations established that a charting error was involved.

The ‘well-known’ rock had been incorrectly charted as being further from the shore than indicated, an issue which highlights the importance of understanding the source data of the chart when passage planning is undertaken. However, the casualty also raised the question of why the ship was allowed to approach within a ship’s length of the shore.

This is an example of complacency, whether in over-confidence, attempted multi-tasking or in under-stimulation, which can also result in a loss of focus. Again the errors are links in the chain but bridge teams should be encouraged to study casualty incidents and use the findings in their own safety management meetings.

Fatigue is also a significant issue for crews. In the case of the grounding of the bulk carrier Sheng Neng 1 on the Great Barrier Reef, the chief officer had been on duty for 38 hours and had less than three hours sleep, a clear contravention of regulations.

The decision to cut a corner to save time, the subsequent failure to programme the new waypoint into the GPS, and a failure to adequately monitor the ship’s position led to a major pollution incident in an environmentally sensitive area.

The amendment to the passage plan introduced an enhanced risk of grounding which was not adequately controlled. This was compounded by the chief officer’s fatigue which resulted in a lack of position fixing and a loss of situational awareness.

Here too, social and cultural issues prevented the second officer from challenging the chief officer’s capability to take the watch because of fatigue. That fatigue was the most probable reason for the failure to determine a reliable ETA at the next waypoint, in circumstances where over-shooting that point would involve critical danger.

In this casualty, Mr Adams says there was a clear case for the Master acting to better manage fatigue, by altering watch patterns to enable officers to rest adequately or even delaying departure. “Fatigue can be a direct result of commercial pressure. As turnaround times shorten there is a risk of a ship putting to sea with a fatigued crew and this elevates risk,” he adds.

Crews are by their nature mixed in nationality but as the ISM Code makes clear, junior officers should be encouraged to challenge senior officers. But this is easier said than done across cultural barriers, where deference is often shown to age and seniority. Adding to the complexity is that while English is the language of shipping, when people panic, they do so in their native tongue.

In the case of the containership Rena, the cost of deviation from the passage plan to try and save a few minutes, was prison sentences for the master and second officer, pollution of the culturally significant Astrolabe Reef and a huge bill for wreck removal.

The now all-too familiar criminalisation process can be lengthy and even when seafarers are exonerated, the trauma can destroy professional confidence. This means fewer masters with less experience are available, exacerbating an already worrying trend.

As the film makes clear, seafaring is an experience-based profession. That experience teaches navigators to recognise conditions and identify situations before they cause an incident. But with increasingly rapid promotion pushing mariners into senior positions, there is a vital need for mentoring, so that knowledge can be passed to those that most need it.

The Club works with its members on a regular basis to help prevent loss: similar DVDs on Collision Avoidance and Piracy are specific initiatives directed towards emergent risk. It has also worked with training safety film provider Videotel to produce over 90 training programmes on a range of topics for use onboard ship.

In the meantime, the best means of avoiding groundings comes down to five words: vigilance, caution, proper passage planning. “If the DVD helps to avoid a single major grounding, it will have been more than worthwhile,” says Mr Adams. “We hope of course that it will do much more than that.”

GROUNDINGS – Shallow Waters, Deep Trouble is available to watch online at: www.steamshipmutual.com/loss-prevention/GroundingsDVD.htm

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