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.

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

Part II—A Lesson in Maritime Management


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


Just before the turn that immediately led to the grounding, the officer of the watch (OOW) was distracted by a phone call on the bridge regarding a disturbance related to a loud party in a stateroom. He was also required to silence a smoke alarm that had sounded on the bridge.

As soon as he felt the ship vibrate from contact with the reef, the master returned to the bridge and assumed the watch of the ship. At about 1:35 a.m. all of the watertight doors were ordered closed to prevent further flooding throughout the ship. The photo depicts the water level in an interior stairway.

At 1:47 a.m., the general emergency signal was sounded, and all passengers and crew were told to report to their emergency/abandon ship stations. By 2:20 a.m. all of the passenger cabins had been evacuated.

At 2:35 a.m. the master intentionally grounded the ship on a sandbar. Since this was accomplished successfully, the decision was made to evacuate the passengers by tenders rather than via the lifeboats. The evacuation was carried out by the shore-based tenders in about an hour and a half.

What Went Wrong?
As with many incidents, no single error caused it. There were organizational errors, navigational errors, and individual human errors.

One of the most critical organizational errors was the master’s not following the standards and procedures as laid out in the ship’s safety management system. Specifically, the officers on the bridge:

• did not set down a written passage plan for this particular deviation;
• did not follow the departure checklist;
• did not take a navigational fix;
• relied on only one navigational instrument, the automatic radar plotting aid (ARPA);
• relied on only one navigational aid, the Proselyte Reef lighted buoy;
• had not updated the charts to reflect the information in the latest Notice to Mariners.

This last item was critical, as the latest notice let mariners know that the Proselyte Reef lighted buoy the OOW was using to navigate had moved 125 meters west of the position on the ship’s chart.

The navigational errors were numerous as well. The officer of the watch did not take an initial fix on the ship’s position and did not account for the current and wind in his calculations. He also relied solely on the automatic radar plotting aid and did not take a terrestrial fix or utilize the global positioning system.

Not surprisingly, the human factors were also many. The master decided to sail to the east side of Proselyte Reef, which is the most dangerous side to transit, as the current moves in a westerly direction, the wind is normally easterly, and the lighted buoy they were navigating by is positioned on the west side of the reef. The master also had a managerial style that did not encourage communication of suggestions or questions by his bridge officers.

Additionally, the other officers of the bridge took no initiative to prepare a passage plan, record the passage of the vessel on the navigation charts, or even take readings from any of the other navigational aids to ensure that the ship was where they thought it was.

What’s the Bottom Line?
Of the multitude of mistakes made that led up to the grounding, many might have not occurred if the master had embraced and encouraged his crew to follow the procedures laid out in the ship’s safety management system.

Part III outlines the human errors and lessons learned from this incident.

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.

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

Part I—A Lesson in Maritime Management

Excerpt from U.S. Coast Guard “Proceedings of the Marine Safety & Security Council” magazine by Ms. Kriste Stromberg, special correspondent to Proceedings.


Lessons learned from USCG casualty reports are regularly featured in Proceedings of the Marine Safety & Security Council magazine. These articles explore marine incidents and the causal factors, outline the subsequent U.S. Coast Guard marine casualty investigations, and describe the lessons learned as a result.

It is important to note that lives were lost in some of the marine casualties we present. Out of respect for the deceased, their families, and surviving crewmembers, we do not mention the name of any person involved.


It’s a beautiful night in the Caribbean. You are aboard a cruise ship, having a wonderful time. You go to bed to rest for the next busy day of port calls and touring. Suddenly, the ship shudders and you are awakened by the captain’s voice over the loudspeaker, stating that there has been an accident and to please move to the emergency stations.

How could this have happened? This is a modern vessel with the latest navigational aids. The officers and crew are all trained and certified. How could this vessel tear open its hull on a well-known coral reef on a clear night with a calm sea? Let’s take a closer look at what happened very early on the morning of December 15, 1998.

The Incident
The ship was on its usual course from St. Thomas, U.S. Virgin Islands, to Martinique when one of the passengers suffered a heart attack and required immediate shoreside medical treatment. The master deviated from his course to offload the passenger.

The ship’s doctor returned to the ship about 1:25 a.m., and the master himself piloted the ship to pass to the east of the Proselyte Reef, not the usual departure route of the vessel.

The master decided on this course based on his mariner’s eye and the information from the automatic radar plotting aid. The master felt that this would provide a safe passage around a known hazard and adequate clearance for a sailing vessel in the immediate area, and so he gave the orders to set sail for Martinique on this path.

About three minutes later, the master, not feeling well, left the bridge to retire to his stateroom. On the bridge were the staff captain, the officer of the watch, and two quartermasters as the helmsman and the lookout. Within another two to three minutes, the ship would tear a hole in its hull on the sharp coral of Proselyte Reef.

In part II, we will examine how this happened.


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.

A Sticky Situation—improving area preparedness through government-initiated unannounced exercises

Excerpt from U.S. Coast Guard “Proceedings of the Marine Safety & Security Council” magazine by LT Kelly Dietrich, U.S. Coast Guard Office of Incident Management and Preparedness, Oil and Hazardous Substance Division and LT Jason Marineau, U.S. Coast Guard Office of Incident Management and Preparedness.


A complete preparedness program must include exercises that catch responders off-guard. As such, unannounced exercises are a key component of our preparedness program and are called government-initiated unannounced exercises, or “GIUEs,” typically pronounced “gooeys.”

These unannounced drills measure initial response actions compared to written actions in vessel and facility response plans. The intent is to identify gaps in the response plans and the ability of the vessel/facility owner to implement a plan before a real incident occurs.

As we re-energize the GIUE program within the Coast Guard’s sector organization, federal on-scene coordinators (FOSCs) need to ensure they coordinate expertise and daily responsibilities housed in both sector prevention and response divisions during the planning and execution of the GIUE through our marine environmental response technical specialists.

Application in Practice
Once the facility/vessel and USCG GIUE team has been identified, the hard work begins. The team should:

• review the facility or vessel history,


• read through the response plan,


• review the geographic response guidance detailed in the area contingency plan,


• draft an appropriate scenario using the main concepts and discharge amounts listed in the facility or vessel response plan,


• select a day and time to conduct the GIUE.

GIUE team members should understand that they are fulfilling two or three different roles:

• Steward of regulations—reviews plans to ensure compliance with vessel and facility regulations.


• Observer—verifies and observes the execution of the response protocols compared to what is listed in the vessel or facility response plan.


• Facilitator—for the vessel or facility person in charge or tankerman on the receiving end of the GIUE, this is a highly stressful situation.

The verification team should approach this situation with full understanding and clear intentions while ensuring the regulations are met.

This effort should not stop at the conclusion of the exercise. Follow-up efforts should be made to identify areas for improvement in training, equipment, planning, and highlighting superior performance.


For more information:
Full article is available at http://www.uscg.mil/proceedings/fall2009.

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Proceedings Fall 2010 Available Online

The current edition of Proceedings (Fall 2010 – Recreational Boating Safety) is available online at http://www.uscg.mil/proceedings/.

This “Recreational Boating Safety” issue highlights the myriad ways in which the National Recreational Boating Safety Program serves to improve marine safety.

Additionally, it gives appropriate credit to the Coast Guard's many recreational boating safety partners and contains ample information about their efforts.

After-Action Reports—the story of an exercise and its response—Part III

Excerpt from U.S. Coast Guard "Proceedings of the Marine Safety & Security Council" magazine. Click here for Part I and Part II.
　

Tips
Reports are only as good as the input received. For a successful evaluation process:

• Identify the correct people to fill the evaluator roles. Each person should be a subject matter expert or have a good working knowledge in the area of the objective that will be tested.
• Ensure that exercise evaluation guides are clear, concise, and contain sufficient information.
• Provide evaluator training prior to the event.
• Review the particulars of the exercise (scenario, location, etc.) with the evaluation team and provide an evaluator handbook.
• Articulate what is expected of an evaluator.
• Conduct data collection immediately or shortly after the event.

By following these basic steps, the evaluation teams will have the necessary tools to accurately capture what happened during the event and be able to provide substantial, quality feedback for the after-action report.

　
For more information:
The Homeland Security Exercise and Evaluation Program toolkit is available at http://hseep.dhs.gov/.

The Department of Homeland Security Lessons Learned Information Sharing site is available at http://www.llis.gov/.

Full article is available at http://www.uscg.mil/proceedings/fall2009.

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

After-Action Reports—The story of an exercise and its response—Part II

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


The Participant “Hot Wash”
This meeting is typically held immediately following the event. Holding it at the functional area of play enables participants to come together to hear about challenges.

This also is a good time to distribute and collect participant feedback forms. All feedback, whether positive or recommendations for improvement, will aid planners as they design exercises or prepare for actual events.

The Controller and Evaluator Debrief
This event may be held directly after the participant hot wash. The primary focus is to discuss and review the controller’s and evaluator’s observations on how responses to exercise events played out.

The debrief should focus on answering questions such as:

• What response actions were triggered at the start of the event?
• Were problems encountered that complicated coordinating resources?
• Did agencies have a notification system in place?
• Were contingency plans used to address what actions were required?
• Did the contingency plans cover the specific event, or were there gaps?

An exercise should not be looked at as a “pass” or “fail” event, but as a method to determine if all aspects of response efforts were addressed. It is also an opportunity to identify issues for corrective action prior to an actual incident.

Additionally, meeting organizers must reiterate the importance of writing complete and comprehensive exercise evaluation guides and establish a due date for the evaluators to submit them to the lead evaluator.

Vetting and Approval
An after-action conference should be scheduled within one month after the exercise. This conference’s outcomes are to solicit feedback for edits to the AAR, develop the improvement plan, and assign a responsible party and due date for each corrective action.

The plan should be a realistic and prioritized list of corrective actions required to improve preparedness. It’s important to note that the improvement plan may only be the first step. Some items may require additional funding or necessitate developing agreements among agencies that share responsibilities or resources during a response.


For more information:
Full article is available at http://www.uscg.mil/proceedings/fall2009.

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

After-Action Reports—The story of an exercise and its response—Part 1

Excerpt from U.S. Coast Guard “Proceedings of the Marine Safety & Security Council” magazine by CDR Ruby Collins, Supervisor, Exercise Support Branch–Detachment 1, U.S. Coast Guard Force Readiness Command.


Following an exercise or event response, we have a tendency to say, “I’m glad that’s over!” For some, however, the work is just beginning.

The After-Action Report
The after-action report (AAR) is the Coast Guard’s official record of an exercise. How important is the AAR to your organization? This report may be the official document required to obtain grants from the Department of Homeland Security, or to receive exercise funds from other sources.

Additionally, a comprehensive AAR will tell you what occurred during an exercise or real-world event. This will allow you to:

• determine if the exercise met program or regulatory requirements,
• identify the obstacles the participants faced and whether they were able to overcome them,
• reveal shortfalls in the response efforts,
• establish training requirements,
• clarify gaps in the contingency plan.

Data Capturing
Participant meetings should be scheduled as soon as possible after an exercise. Facilitators can draw people into the discussion by asking questions, reading body language, and keeping the group focused.

Initial feedback can be used to develop a “quick look” report—three items that went well and three items that require additional attention—that is helpful in crafting the final after-action report.


For more information:
Full article is available at http://www.uscg.mil/proceedings/fall2009.

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

Joint Exercises, Half the Headache

Excerpt from U.S. Coast Guard “Proceedings of the Marine Safety & Security Council” magazine by CDR Heather Kostecki, Planning and Force Readiness Department Head, U.S. Coast Guard Sector San Francisco.


In the exercise community, we often hear the term “exercise fatigue,” since with each new regulation and guideline comes a new requirement to conduct exercises. Many planners find themselves overwhelmed about how to meet the requirements and how to balance readiness needs against resource limitations.

More Exercises, Same Resources
One answer is to combine exercises to maximize available funding and manpower. Ports have started pairing area maritime security exercises with oil spill response exercises, and hurricane exercises with mass rescue operation exercises.

However, exercise creep (attempting to address too many issues within one exercise) can rapidly derail the exercise. Also, if not planned with a focus on coordinated operations, a combined exercise can turn into two exercises taking place at the same time.

Failure to establish interconnectivity between the exercises results in lost opportunities to explore the “rub points” that will occur when actual operations with different goals occupy the same space and compete for the same resources.

A Long-Term Solution
One way to address the issue is by producing a long-term exercise schedule that is systematic and regional in nature to achieve economies of scale and synergy.

FEMA regional training and exercise plan workshops, for example, allow regional partners to see what other exercises may be occurring that cover the same territory as their own, with the opportunity to combine efforts.

Combining exercises can be accomplished successfully if planners link exercises very deliberately and thoughtfully. All parties need to be apprised of the scope of play from the beginning, and must hold firm to that scope despite pressure to tack on “just one more” issue. Most importantly, the issues being evaluated must continue to meet all statutory requirements for each of the participating programs.

Members of different response communities in a port should meet well in advance of a planned combined exercise to learn what each community does during a response, what their jurisdictional boundaries are, and each community’s authorities and capabilities.


For more information:
Full article is available at http://www.uscg.mil/proceedings/fall2009.

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

Upcoming in Proceedings

Fall 2010: Recreational Boating Safety (RBS)
• RBS program synopsis
• State RBS involvement
• RBS partners
• Manufacturing standards
• USCG Auxiliary
• Small vessel security
• Lessons Learned: Barkald/Essence: A routine passage turns tragic.

Winter 2010-11: Fishing Vessel Safety
• Commercial Fishing Vessel Safety Program synopsis
• Mitigating risk
• Training and outreach
• Collaborative efforts
• Lessons Learned: Lady Luck: A small fishing trawler suddenly sinks and disappears.

Spring 2011: Waterways and Maritime Transportation Systems Management
• Domestic waterways management
• International work and initiatives


Your Opinion
• What do you want to read in Proceedings?
• What area under the Coast Guard’s marine safety, security, and environmental protection missions affects you most?
• What do you want to know more about?

Post a comment here or send us an e-mail at HQS-DG-NMCProceedings@uscg.mil.

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