WATCHOUT How rapidly developing risks led to ship grounding

30 Jan 2023 The Navigator

In this series, we take a look at maritime accident reports and the lessons that can be learned.

What happened?

A containership set off on its journey with a pilot on the bridge, along with the Master and the rest of the bridge team. After a time, the Master left to get dinner, while the pilot remained on the bridge along with a third officer, deck cadet and an able seaman at the helm. A passage plan was in place – but when the vessel passed a charted waypoint which required a turn, no order was given – and no turn was made. The ship continued on its previous heading, left the channel, and quickly ran aground.

Why did it happen?

The pilot was relying solely on his portable pilot unit (PPU) to navigate. Moments before the grounding took place, he had exited the active navigation function on his device to view a previous transit. He had been distracted from assessing the passage plan and associated risks by making five separate phone calls that took up more than an hour of his time collectively, and by starting to draft an email immediately before the grounding occurred.

There were no mechanical faults or equipment failures. The pilot and bridge team did not take into account the fact that risks can happen, and situations change, very rapidly while at sea, or make the most of the risk management measures that were already in place, including the passage plan and BRM procedures. The whole team must remain alert for such changes and react to mitigate against potential risks as soon as they become apparent.

What changes have been made?

  • The report recommended reviewing policies around the use of mobile phones and other portable electronic devices on the bridge. In particular, it emphasised the dangers of fixating on electronic devices or relying too heavily on one piece of equipment while navigating or carrying out safety-related functions.
  • Vessel owners and operators were also urged to promote the importance of effective communications between the Master, bridge team and pilot.

You can find the full report at EverForwardGrounding_ROI_Redacted.pdf (uscg.mil)

THE PILOT AND BRIDGE TEAM DID NOT TAKE INTO ACCOUNT THE FACT THAT RISKS CAN HAPPEN, AND SITUATIONS CHANGE, VERY RAPIDLY WHILE AT SEA

If you find our accident reports useful, check out The Nautical Institute’s Maritime Accident Reporting Scheme (MARS). A fully searchable database of incident reports and lessons, updated every month. Seen a problem yourself? Email the editor at Mariners’ Alerting and Reporting Scheme mars@nautinst.org and help others learn from your experience. All reports are confidential – we will never identify you or your ship.

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