Lessons Learned—The Grounding of a Cruise Ship—Part III

Part III—A Lesson in Maritime Management

Excerpt from U.S. Coast Guard “Proceedings of the Marine Safety & Security Council” magazine. Read Part I and Part II here.


The ship’s safety management system intends the bridge officers to work as a team, with checks and verifications of tasks accomplished. However, there was evidence that the master’s abrasive personality created reluctance among the crew to disagree or question the master’s decisions. This attitude of unquestioning subservience established an unsafe condition.

As stated in the casualty report:

“The lack of teamwork arose due to the master’s failure to involve the watch standers in the decision-making process regarding the departure route, as well as the master’s overbearing presence. The senior members of the navigational team expressed their surprise at the unusual and more dangerous departure course, but failed to express their concern because they did not feel empowered to voice doubt in the master’s decisions.”

Ergonomic and Human Performance Issues
The officer of the watch’s decision to rely solely on the automatic radar plotting aid (ARPA) to plot the Proselyte Reef lighted buoy as the sole reference point was contrary to the rules of good seamanship, his training as a navigational officer, and the vessel’s established standard procedures.

This was combined with a poor layout of the navigation station, which made it much more difficult to use the ARPA as well as the other navigational aids aboard the vessel. The chart table was placed well away from the automatic radar plotting aid, which was at the forward starboard side of the bridge. While this position allowed a good view of traffic, all other navigation instruments as well as the charts were located well away from that position.



It was also discovered that the navigational watch officers relied on the electronic instruments rather than taking terrestrial navigational fixes. Taking terrestrial navigational fixes is time-consuming, requiring placement of the azimuth bearing circles on the gyro repeaters, taking bearings, and then plotting them. On this vessel, the gyro compass repeaters were blocked by equipment cowlings, as depicted here.


The officer of the watch also failed to fully utilize the automatic radar plotting aid’s capabilities. He never ground-locked the ARPA nor did he manually input the wind and current values that would have allowed the ARPA to calculate the vessel’s set and drift. If he had, he might have realized that the ship was a lot closer to the reef than he thought.

Lessons Learned
The investigation report noted more than a dozen different recommendations, which can be summarized:

• Operate as a team and communicate clearly with each other, especially when making an emergency or non-routine operation.
• Separate hotel management responsibilities from the bridge crew to ensure that hotel problems do not compromise the safety of the ship.
• Plan passages and make written records of the plans.
• Keep charts current and corrected.
• Practice good seamanship and do not be over-confident about your abilities or those of your ship or the ship’s instruments.
  

For more information:
Full article is available at www.uscg.mil/proceedings. Click on “archives” and “2006 Volume 63, Number 2” (Summer 2006).

Subscribe online at http://www.uscg.mil/proceedings/subscribe.asp.