Abandon Ship! - How navigational complacency sane a passenger ferry

01 Oct 2012 The Navigator

Never is the navigating officer more crucial than in ensuring the safety of a ship and its crew at sea. Responsible primarily for human lives, they also safeguard valuable cargo, plus the ship itself and environmental safety. In this series, we take a look at maritime accident reports and the lessons that can be learned.

A passenger and vehicle ferry carrying more than 100 passengers and crew set sail for a short scheduled voyage. At 00.21 hours the following morning, the vessel struck the north-east side of an island, drifting for over an hour before sinking, causing substantial damage and the tragic loss of two human lives.

What happened?
The eight-deck passenger roll-on/roll-off vehicle ferry departed port at 20.00 hours. She was equipped with fully functioning navigational equipment, and her bridge team was made up of the Master, Second Officer, two Quartermasters and a Fourth Officer.

At 23.50 hours, the steering was set to auto-pilot. The Master had already retired for the night, and the Second Officer left for his break at midnight after reporting a small southbound fishing vessel ahead. The First Quartermaster, who was at the helm, talked intermittently with the Fourth Officer: it had been reported that the pair were in a relationship which was experiencing problems.

Two minutes after midnight, a squall of heavy winds and rain reduced visibility. The fishing vessel was heading east to seek shelter from the weather and was no longer visible on the ferry’s radar. No attempt was made to communicate with it; instead, conversation resumed between the bridge officers.

At seven minutes past midnight, the ferry passed the point where she needed to make a course-alteration to avoid collision with an island a little way ahead. This change was never set, although the Fourth Officer somehow believed it had been. It took 13 minutes to spot the error, due to various distractions. In addition, the ECS screen had been dimmed and audible alarms deactivated.

As the First Quartermaster stood to make the change at 00.20 hours, she saw trees on an island off the starboard bow. The Fourth Officer ordered her to switch from auto-pilot to hand-steering. She was, however, unfamiliar with the forward steering station and did not know how to comply. DGPS data analysis revealed little or no aggressive action taken to right the ship’s course as it headed inexorably for the island, striking at 00.21 hours.

The ferry struck along the island before drifting north. The Second Quartermaster tried to reverse her progress, while the Master ordered the watertight doors – some of which had remained open – to be closed. One door was blocked by debris and could not be shut, causing rapid water ingress to the hull. Listing severely, the ferry sank by the stern, coming to rest on its keel. 

Passenger evacuation was chaotic, hampered by inexperienced crew members and no established evacuation plan. Head counts revealed differing figures, with the tragic result of two unaccounted for passengers being declared dead.

What changes have been made since?
Since the incident, the passenger reservation system includes all names and boarding numbers. Enhanced training ensures all bridge officers and quartermasters are familiar with both onboard equipment and effective


Kay facts

  • The working environment on the ferry’s bridge was not formal. Officers were allowed to become distracted by personal issues, resulting in catastrophic navigational mistakes
  • The First Quartermaster was unfamiliar with the ship’s navigational equipment and did not have a valid bridge watchman certificate
  • The navigational officer did not reduce speed when visibility grew poor due to adverse weather conditions, nor when a fishing vessel ahead changed course, vanishing from the ferry’s radar
  • The ferry’s course was not altered as required causing her to head straight for an island
  • Navigational system alarms had been switched off and the ECS screen dimmed, preventing prior warning of the erroneous course
  • Action taken when the mistake was spotted was deemed ‘too little, too late’ 
  • Passenger evacuation was ‘chaotic’
  • Deficiencies in passenger registration: not all names had been recorded on the passenger manifest