93066 Grounding of the QE2

Official Report No. 7010

Last month I listed the conclusions and recommendations of the MAIB drawn from their report on the grounding of the QE2. I now have the reports of the US National Transportation Safety Board and the US Coast Guard into this incident and it is interesting to compare the different reports. It is important to identify how such an incident can occur on a vessel which has an adequate supply of well trained, highly qualified officers and good equipment.

Due to a delay in boarding the returning passengers, the vessel departed from the anchorage near the town of Oak Bluffs at 2050, 50 minutes after the scheduled departure time. The Master initially had the conn and turned the vessel on to the correct heading before handing over to the Massachusetts State Pilot, the same Pilot who had guided the vessel into Vineyard Sound earlier that day. The pilot testified that after the anchor was raised, "There was, as I recollect, a small discussion about what time we would make the pilot station and if we could run at a good speed. We would primarily follow...the inbound passage".

The Bridge Team on leaving consisted of Master, Pilot, Staff Captain, First Officer (1/O) on the 8 - 12 watch, Quartermaster and Helmsman. When the anchor was aweigh the 8 - 12 Second Officer (2/O) joined the Bridge Team and the Staff Captain departed. No language difficulties were reported between the pilot and the navigation watch on the bridge. One radar was available for use by the Pilot, whilst the 2/O used the other radar to fix the vessel's position. Two recording echo sounders were operating in the chart room, the analogue echo sounder in the wheelhouse was inoperative.
At approximately 2115, the vessel rounded West Chop at the north end of the Vineyard. After local marine traffic had cleared sufficiently, the ship's speed was increased from 15 to 18 knots. The vessel's position was plotted every 6 minutes. The Navigator had previously plotted a trackline on Chart BA 2456 that was clear of the 36 foot depth near the NA buoy but passed over a 40 foot sounding 0.5 mile ESE of the buoy. He plotted the trackline well south of the 10 fathom contour line , which enclosed the rocky area that had a 39 foot depth sounding, about 2.5 miles south of Cuttyhunk Island or about 1 mile south of Sow and Pigs Reef. This shoal, and others, were "hatched in" on the chart by the Navigator to indicate that persons using the chart should "be aware of this area".

From leaving the anchorage until 2148 the positions were plotted on chart NOAA 13233 as well as chart BA 2456, (after 2148 positions were plotted on BA 2890 only). At 2124 the speed was increased to around 24 knots at the Master's request and with the concurrence of the Pilot. At 2144 the QE2 passed the NA buoy. With the buoy abeam to starboard the Pilot altered course to 2500 He testified that he intended to maintain that course until he was approximately 2 miles south of the SW point of Cuttyhunk Island then steer 2700 to where he would disembark. These courses were not the same as those the Navigator had put on the chart and were not the same as the inbound courses.

At the hearings there was some conflict in the recollection of the witnesses as to whether the alteration was to 2480, 2500 or 2550. There is also conflict between the reports on this point. The MAIB suggests that 2500 was the most probable course, whereas the NTSB report says that analyses of the course recorder trace indicated a course of 2550. This however, has very little to do with the cause of the incident.

At 2148, after the vessel steadied on a new course, the 2/O plotted the position of the vessel on chart BA 2890. He then projected an anticipated track, based on the new course being steered. The projected track passed through the "hatched in" area on the chart NE of Brown's Ledge. Here again, conflict arises in the reports. The MAIB says that the pilot consulted the chart at this time and the 2/O drew his attention to the projected track. A decision to pass S of Brown's Ledge was then agreed between the Master, the Pilot and the 2/O and the heading was altered to 2400. According to the NTSB, when the 2/O saw that the trackline passed over the "hatched in" area he told the 1/O who, in turn, told the Master. The Master then told the 1/O to tell the Pilot that he would rather pass further south of the Sow and Pigs Reef and towards the original trackline marked on the chart. Shortly before 2154 the course was altered to 2400.

After he had drawn the projected track of 2400, the 2/O noticed that it passed over a sounding on the chart of 39 feet, he was not unduly concerned about this as he was aware that the draught was 32 feet 4 inches. He said nothing to the Pilot or others on the bridge. The Master and Pilot had looked at the chart and noted that the projected trackline passed clear and south of Brown's Ledge. They seemed satisfied with this information and there attention was not drawn to the 39 feet sounding. According to the Pilot, the predicted height of the tide during the passage out of Vineyard Sound was approximately +1.5 feet. Both the Master and the Pilot testified that they considered passing over a 39 feet sounding with a +1.5 feet tide was not a problem.

At 2158 the vessel experienced two periods of heavy vibration in quick succession. As the second vibration was ending, the Master ordered the vessel stopped. Mechanical failure was at first suspected but it was soon realised that the vessel had struck some underwater objects. The well planned emergency procedures aboard the vessel quickly swung into action and it was ascertained that several double bottom tanks had been breached. The 1,003 passengers on board were made aware of the situation. The vessels stability was not impaired and no-one was injured but there was extensive damage to the outer hull. All passengers were subsequently transferred ashore prior to the vessel proceeding under her own power to dry dock and spending several weeks undertaking repairs.
The NTSB report determined that the probable cause of the grounding was the failure of the Pilot, Master and Watchkeepers to discuss and agree on a passage plan and to maintain "situational awareness" after an unplanned course change.

Contributory to the accident was the lack of information regarding squat. The USCG report comments that: The information on underkeel clearance obtained from the David Taylor Research Centre (DTRC) and the British Maritime Technology (BMT) indicates that many factors are involved in the sinkage and trim of high speed ships in shallow water and that the influence of these factors on a particular ship is not well understood. For example, DTRC computer simulations had a bow down attitude immediately before the grounding, while BMT model tests indicate a stern down attitude. Literature searches demonstrate a lack of information on shallow water effects of high speed ships.

The NTSB report also considers at length the apparent lack of Bridge Resource Management (BRM). BRM stems from ideas developed in the aviation industry in response to an increasing number of accidents caused by the failure of flight crew members to co-ordinate critical information. This is achieved by teaching the use of teamwork to optimise the available resources such as, hardware software and personnel, to foster effective decision making during critical periods. This is achieved by identifying and making flight crew aware of communication barriers: namely, the existing culture about behaviour, team members attitudes about their respective responsibilities and personality types that conflict with the team approach to problem solving.

According to the NTSB report, when the QE2 departed from the original trackline the 2/O reported this to the 1/O who in turn alerted the Master. The Master then relayed his observations through the 1/O to the Pilot. Although this method of information transfer allowed for strict control of accuracy of information and responsibility for communication, it also required time for each participant in the chain to react individually. More important, the chain segregated the navigational activities of the ship's officers from the Pilot's navigational activities. Thus no-one on the bridge was aware of the immediate implications of the Pilot's abrupt altering the ship's course back towards the original trackline. BRM requires that all pertinent sources of information flowing on the bridge to be shared among the Bridge Team so that critical decisions can be made by the Master with the best information that the Team can collectively present. The Pilot's knowledge and expertise of local waters should be integrated into the Bridge Team's flow of information. BRM applies to this accident in that all members of the QE2's Bridge Team should have been more communicative and aware of the vessel's status, performance and general situation so that they could contribute to the operational decision making.

This proposal is justified if events unfolded in the way described in the NTSB report, however, if the Pilot consulted the chart and the 2/O expressed his doubts about the projected course to him, as suggested by the MAIB, it puts a different light on the matter. Whichever way it happened, I think that the ideas behind BRM are sound and may well have helped to avert this accident. The flow of information between the Pilot and the Bridge Team should be as comprehensive as possible, as should that between the Officers and the Master. A course of training in BRM techniques designed by the SAS Flight Academy has now been developed by a group of interested bodies in Europe.

The concept of using both the American and British charts for the area is no doubt very commendable, however, transferring fixes from one chart to the other considerably increased the workload of the 2/O, leaving him little time to consider the implications of course changes and increasing the possibility of making an error.