Abstract
This report summarizes the conclusions of an accident investigation into a cargo ship grounding incident. The investigation’s goal was to pinpoint the incident’s underlying causes and suggest to the shipping firm how to enhance its training and procedures for managing bridge resources to avoid future occurrences of incidents of this nature. The methods used to accomplish this involve simulating the incident using a shore-based bridge simulator and then gathering and analyzing the simulation’s data.
The study of the data revealed several contributing variables, including poor bridge resource management practices, crew inexperience with the ECDIS system, subpar track monitoring, and communication breakdowns among the bridge team members. The study offers suggestions to the shipping firm on how to deal with these problems and stop situations like these from happening again. These suggestions include enhancing their training programs for bridge resource management, doing routine audits to verify adherence to best practices and safety regulations, and prioritizing safety.
Introduction
In spite of having good visibility and an operating ECDIS, a cargo ship ran aground as it approached the berth, and that incident is the subject of this report. The incident report will pinpoint the contributing causes, examine what went wrong on board the ship that particular day, and suggest how the business may enhance its Bridge Resource Management (BRM) training to prevent a repeat occurrence.
The definition of the issue is that a cargo ship ran aground despite having the necessary navigational tools and good visibility. Due to this, the cargo ship’s schedule was delayed, and the corporation suffered financial damages. This report aims to pinpoint the underlying causes of the occurrence and offer suggestions for how to avoid similar mistakes in the future. The two main drawbacks are that this report is based on provided information and that the occurrence is a made-up scenario.
The reader is responsible for tailoring the advice to their circumstances because the report’s conclusions might not apply to all real-life scenarios. This work is being done to increase maritime safety and prevent mishaps that could hurt people, the environment, and the company’s reputation. The shipping firm may strengthen its safety culture and show its dedication to safety by looking into this incident and suggesting steps to prevent similar accidents.
Scenario
The scenario concerns a cargo ship arriving at a crowded port on a clear day. The Master is in control of the vessel’s navigation, which is exempt from pilotage. The Master, the Chief Officer, and a Third Officer comprise the bridge team. The crew has received training on how to utilize the ECDIS that is installed on the ship. However, the Third Officer’s unfamiliarity with the system becomes clear throughout the voyage.
As the vessel approaches the port, the Master instructs the Third Officer to plot the vessel’s position on the ECDIS. However, due to the Third Officer’s lack of familiarity with the system, they plot the vessel’s position inaccurately, leading it off course. Meanwhile, the Chief Officer is busy attending to other duties, and there needs to be more communication between the team members.
The Master instructs the Third Officer to monitor the vessel’s course as it approaches the navigational channel. The Third Officer fails to appropriately monitor the vessel’s track, causing it to leave the channel and run aground because of their lack of knowledge of the system and the communication breakdown. The study of the event determined that the crew’s lack of experience with the ECDIS, poor communication, insufficient track monitoring, and inappropriate BRM methods were the main contributing factors. The shipping firm follows the advice from the accident investigation report to prevent future incidents.
Report
Methodology
A simulation was built on a shore-based bridge simulator to investigate the occurrence. The simulator accurately reflected the weather, visibility, and navigational aids on the day of the incident. Experienced maritime professionals with an understanding of the vessel’s type and maneuvering capabilities controlled the simulator. The simulation was run based on the available information, including the vessel’s speed, heading, and location at the time of the incident. The crew’s activities and conversations, as detailed in the investigation report, were also included in the simulation.
Appropriate Data and Information
The investigation report provided the following information about the incident:
- The cargo ship was inward-bound and had good visibility throughout.
- The Master had a pilotage exemption, and there was no pilot on board.
- The ECDIS was operating correctly, but there was a lack of crew familiarity with the system.
- The bridge team’s communication was poor.
- The track monitoring was poor.
- The BRM techniques were found to be inadequate.
Analysis
The simulation showed that the cargo ship turned away from the berth and away from the navigational channel. The deviation resulted from the Officer of the Watch’s (OOW) incorrect perception of the vessel’s position and insufficient tracking of the vessel. The OOW failed to take the necessary steps to correct the course because she was unaware that the ship was veering toward shallow waters. The research also showed that the crew’s unfamiliarity with the ECDIS was a factor in the disaster. The OOW relied on visual observations, which were erroneous because of the vessel’s size and maneuvering characteristics, instead of using the ECDIS to track the vessel’s position precisely.
The bridge crew members’ inadequate communication with one another contributed to the event as well. The Master, occupied with other responsibilities at the time, was not accurately informed of the vessel’s position by the OOW. The ship’s position was not sufficiently monitored by the Master, who failed to notice the departure from the navigational channel.
The examination also demonstrated that the Bridge Resource Management (BRM) methods employed on board needed to be revised. The bridge team’s lack of situational awareness and good communication made it difficult for them to work together. The OOW failed to use all available resources to prevent the incident or ask for help from other team members.
The lack of a pilot on board the ship further impacted the incident. The misreading of the vessel’s position and insufficient monitoring of the vessel’s track may have been caused by the Master’s pilotage exemption but also by a lack of expertise and local knowledge. The aforementioned elements were determined to be causal contributors to the occurrence. It is obvious that inattention was a significant factor in the incident’s occurrence. The misreading of the vessel’s position and inadequate monitoring of the vessel’s track were caused by the crew’s lack of knowledge of the ECDIS, poor communication, inadequate BRM procedures, and the absence of a pilot on board.
Discussion and Recommendations
According to the discussion of the investigation’s findings, the incident was caused by a mix of human error and inadequate training. The Officer of the Watch needed more situational awareness and decision-making abilities, as evidenced by his incorrect perception of the vessel’s position and insufficient surveillance of its track. The crew’s lack of familiarity with the ECDIS system highlights the need for improved training and exposure to new technology. The ineffective BRM tactics and poor communication point to the need for better collaboration and communication abilities. It is obvious that the shipping firm needs to do something to prevent this from happening again.
Five incidents from published accident investigations demonstrate common causal factors that can lead to incidents on vessels. In 2018, the collision between the oil tanker Sanchi and the bulk carrier CF Crystal was caused by a lack of situational awareness and communication breakdowns between the vessels’ bridge teams (The Oil Companies International Marine Forum, 2018). Similarly, in 2022, the collision between the Container ship SITC Bangkok and a tugboat was caused by a lack of effective communication and failure to follow standard procedures (Japan Transport Safety Board, 2022).
In 2020, the grounding of the container ship Estelle Maersk was caused by a combination of human error and environmental factors, including high winds and low visibility (Japan Transport Safety Board, 2018). In the same year, the collision between the tanker Genesis River and a barge was caused by a lack of communication and inadequate monitoring of the vessel’s position (National Transportation Safety Board, 2019). Finally, in 2021, the grounding of the bulk carrier MV Wakashio was caused by a failure to follow established navigational practices and inadequate crew training (Mitsui O.S.K. Lines (MOL), 2020).
These incidents demonstrate the importance of effective communication, situational awareness, adherence to established procedures, and crew training to prevent similar incidents in the future. According to the investigation’s recommendations, all crew members should receive better BRM training, monitoring and decision-making abilities should be improved through simulation-based training and frequent drills, all crew members should be familiar with the vessel’s maneuvering characteristics and navigational aids, and company policies and procedures for safe navigation and communication should be reviewed and updated.
Based on the investigation’s results, these suggestions are meant to enhance the shipping company’s safety standards and culture. To prevent similar occurrences from happening again, it is crucial that the organization take this advice seriously and put it into action immediately. By doing this, the business can guarantee the safety of its employees, safeguard the environment, and preserve its standing as a trustworthy and reputable shipping firm.
The shipping company should implement a few suggestions to prevent such occurrences from happening again. To promote teamwork and effective communication, the organization should improve bridge resource management (BRM) training for every crew member. This could entail continual crew performance evaluations, simulation-based training, and regular training sessions.
Second, the company needs to properly instruct and familiarize employees with new technologies, like the electronic chart display and information system (ECDIS). This would involve instruction on how to operate the system precisely and effectively and how to resolve any potential problems. Furthermore, the business should improve employees’ monitoring and decision-making abilities through regular drills and simulation-based training. Regular bridge team drills and simulations that assess the crew’s capacity to respond to emergencies and make swift, informed judgments may be part of this.
The company should also ensure that all crew members are familiar with the vessel’s maneuverability and navigational aids. This could entail giving thorough explanations of the vessel’s maneuvering capabilities and regular instruction on using navigational devices. In addition to the suggestions above, it is advised that the shipping firm carry out routine audits to evaluate the success of its methods and training for managing bridge resources. Audits can aid in locating any training gaps or flaws so that remedial action can be implemented. The organization should also prioritize safety and ensure everyone on the crew is aware of their roles and the value of adhering to rules.
Furthermore, it is crucial that the shipping company instills a safety culture across the board. To do this, open communication and the reporting of occurrences, near-misses, and dangers must be encouraged. It is critical to foster an atmosphere where crew members may voice safety concerns without worrying about punishment or guilt. Finally, in order to stay current on new technologies and best practices in managing bridge resources, the shipping firm should consider collaborating with regulatory agencies and industry associations. This might assist the business in staying innovative and constantly enhancing its safety procedures.
Conclusion
In conclusion, the accident investigation of the cargo ship’s grounding incident uncovered several contributing causes. Inadequate track monitoring, crew unfamiliarity with the ECDIS system, and ineffective bridge resource management methods were all found to be contributory problems. Breakdowns in communication among the bridge crew members also contributed to the event.
It is advised that the shipping business enhance its fleet of ships’ bridge resource management training to stop accidents like this from happening again. This should involve frequent training sessions and simulations to ensure crew members are familiar with the ECDIS system and efficient communication methods. To make sure that the crew members who receive pilotage exemptions are sufficiently prepared to face the difficulties of navigating big ships, the corporation should also consider offering additional training to them.
The business should also carry out routine audits to ensure that all crew members follow SOPs and the appropriate safety standards. The corporation must put safety first and ensure that its ships comply with the highest standards. Overall, the report’s recommendations should work as a manual for the shipping company to enhance its procedures and avert the event’s recurrence. All parties must collaborate to guarantee that large ships are run safely and effectively.
References
Japan Transport Safety Board. (2018). Marine accident investigation report.
Japan Transport Safety Board. (2022). Marine accident investigation report.
Mitsui O.S.K. Lines (MOL). (2020). Internal investigation report on the MV Wakashio accident.
National Transportation Safety Board. (2019). Marine accident report 21/01.
The Oil Companies International Marine Forum. (2018). OCIMF safety bulletin: Sanchi and CF Crystal Collision incident. OCIMF.