202537 Speed and distractions end with a bump

As edited from SHK (Sweden) report 2025:04

In the early morning, a crew of three were bringing a small ferry to its departure port for the first run of the day. Having just left the sleep-over port in darkness, the captain found that the displays of the two engine monitoring instruments were shining too brightly, hampering his night vision. The displays were located to the left of the driver’s seat, but access to them was constrained by the left armrest of the chair. Once out in the fairway, the captain activated the autopilot that was integrated into the left armrest. He then raised the armrest and attended to the displays.

To dim the light on the displays, two buttons had to be pressed simultaneously. The buttons were not backlit, so the captain took out his mobile phone and activated the flashlight function to see better. With the phone in one hand, he pressed two buttons simultaneously with the other hand. On his first attempt the display went completely black instead of dimming. Concentrating on this task for a second time, he saw something appear in front of the ship. With no time to turn away the ferry ran aground on an island at a speed of almost 16 knots.

The investigation found, among other things, that the autopilot’s ‘change in operating mode’ warning was not effective. The autopilot probably became disengaged when the armrest was raised to give the captain access to the engine monitoring displays, without him being aware of this. At nearly 16 knots, it only took a few seconds for the ferry to veer off course and run into danger while the captain was preoccupied with dimming the panels.

 

Lessons learned

• Poor design and ergonomics are nefarious unsafe conditions that often go unnoticed until it is too late.
• In darkness and navigating the vessel in a restricted waterway, the captain was trying to undertake an adjacent task that takes both hands and both eyes.
• Once again speed is an issue. At 16 knots the captain did not put chance on his side when deciding to attend to an adjacent task.
• A seaman was sitting in the aft part of the wheelhouse without duties. He would have been more useful as lookout.

Full report can be found here: