Crimson Mars Investigation

August 10th, 2007 by JCB
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CRIMSON MARS GROUNDING

Read the full ATSB report www.atsb.gov.au/publications/investigation_reports/2006/MAIR/pdf/mair227_001.pdf

One of the first lessons I was taught when training to pilot VLCC’s onto Single Buoy Moorings in Nigeria was the importance of checking that the helmsman put the wheel over as ordered and not to be shy about even gesticulating with arm movements to reinforce the verbal command when issuing helm orders. My thoughts that Peter Snow type gesticulations on the bridge might make me look a bit foolish were dismissed by the training pilot with the observation that in view of the potentially adverse consequences of such an error, I would look rather more than foolish if the helmsman put the wheel over the wrong way! 25 years on, and although now piloting on the Thames, that lesson is still valid and is one that I now instil in new trainee pilots. It does seem strange that in the 21^st century, where technology is so dominant, such basic techniques can still have relevance but as every pilots knows it is not that uncommon for the helmsman to put the wheel over the wrong way and the consequences of such errors going undetected will invariably result in a grounding or collision in pilotage waters.

One such error brought the lesson firmly home last year when the woodchip carrier Crimson Mars grounded whilst departing from Port Dalrymple in Northern Tasmania. The approach channel to Port Dalrymple looks narrow and winding but the pilot had been working in the port for 13 years so was presumably well experienced in handling large ships in the channel. On this occasion the ship was proceeding at full manoeuvring speed into a flood tide which gave a speed over ground of about 10 kts. At a critical turn the pilot claimed that he ordered port 10 but the helmsman claims that he ordered starboard 10. Observing that the ship was not responding, the pilot thought that the flood tide was acting on the port bow thus reducing the effectiveness of the rudder and claims to have ordered port 20 closely followed by “hard to port”, again the helmsman recalled the order being starboard. Noticing that the vessel was now swinging to starboard the pilot checked the helm indicator and then noticed that the helm was hard to starboard. Although the engine was put full astern and the anchors were let go the vessel grounded shortly afterwards causing major damage to the bulbous bow.

The official report goes into detailed analysis of the events leading up to the grounding but it is evident that in common with many pilotage acts the pilot alone was ‘the bridge team” and since neither the Master nor the officer of the watch (OOW) recalled either the helm order given by the pilot or the acknowledgement by the helmsman it is obvious that the passage was not being monitored in accordance with “best practice” procedures! This accident happened in good visibility and in daylight and it is evident from the chart that, had anyone on the bridge been paying even minimum attention to the passage then with land to starboard, a reef a couple of cables right ahead and the channel to sea open on the port bow that a starboard helm order was probably not going to achieve much other than a disaster and this would therefore tend to support the pilot’s statement of helm orders and that the helmsman put the wheel over the wrong way. Investigators are always incredulous that such failures can occur on even well found vessels, pilots just reflect that “There but for the grace of fate go I”! Such is the reality of pilotage and this incident serves to confirm my own “Theorem of Pilotage” that the difference between a good pilotage manoeuvre and a bad pilotage manoeuvre is 10 seconds inattention and the difference between a successful pilotage act and a disastrous one is 20 seconds inattention!

As with all these investigations we should all learn lessons and returning to my introduction, the Australian investigators provide the following recommendation regarding helm orders, “They should also ensure that the conventions governing helm orders are observed, particularly the use of ‘midships’ when changing rudder direction, and ‘closing the loop’ when communicating orders to a helmsman. The use of hand signals to enhance the communication of helm orders should also be considered”.

As I understand it “closing the loop” refers not just to the established practice of the helmsman repeating the order back to the pilot but also the traditional best practice of confirming when the instruction has been executed.

The rudder angle indicator

The other key recommendation for pilots in the report is that “Pilots and masters should ensure that they are able to read, or otherwise be able to check, the rudder angle when conning a ship”.

This is a very significant recommendation in that it highlights once again the fact that new ships are still being constructed with appalling ergonomics which totally fail to provide an efficient navigation centre. Although only launched in 2002, the Crimson Mars had a “traditional” wheelhouse arrangement (see plan) virtually undistinguishable from those found in the 1960’s with the engine telegraph on one side of the bridge, the radars on the other and the helmsman in the middle. The instrumentation is also unchanged from the Japanese design of the1970’s with various pale green instrument readouts (will the stock never run out?!), including the helm indicator, sighted above the centre wheelhouse window directly above the pilot’s head at the normal conning position. All this reality is far removed from the utopian dream of the “e-navigation” proponents! Because of the cranes mounted on the centreline of the ship, the class rules for the Crimson Mars require two additional “conning” positions with a clear view forward and the pilot was conducting the ship from the starboard position adjacent to where the radars were sighted at the time of the incident. The report considers it significant that there was no helm indicator visible from this position stating that “If the incorrect use of starboard rudder had been observed earlier the grounding may have been prevented”. It goes on to note that

SOLAS, Chapter V, Regulation 12 states “… ships … shall be fitted with indicators showing the rudder angle, the rate of revolution of each propeller … All these indicators shall be readable from the conning position”. This would tend to suggest that the arrangement on board the Crimson Mars was not compliant. Not so, the report states the following with respect to this:

During the investigation Class NK ( The ship’s classification society Nippon Kaiji Kyokai)

advised the ATSB that they interpret this (SOLAS regulation)to mean that all indicators required by the provisions of the SOLAS regulation should also be readable from the ‘additional conning positions’. Class NK also stated that these positions are normally located approximately 2.5 m from the conning position which is usually on the centreline and that the indicators near the centreline are not difficult to read from such positions. They required additional indicators when additional conning positions were distant from the centreline such as on bridge wings.

The photo clearly reveals that this is not the case and as we all know, even at the centre line “conning position” if the pilot is standing in front of the window next to the compass repeater he cannot see the rudder indicator above his head without an awkward contortion risking serious neck dislocation.

Returning to the report it is evident that the ATSB is not convinced by the interpretation of the rules by Class NK but, as with most investigations, fails to actually condemn the interpretation (mustn’t make waves which might upset the status quo!). I have read it several times and can only conclude that it is non committal waffle. Perhaps someone more perceptive than me can decipher the meaning so I have reproduced the following relevant section directly from the report, grammatical errors included:

Extract from report section 2.3 Conning Position (Page16)

In submission ClassNK stated:

The aim of the additional conning position is “giving a clear view”. SOLAS Ch. V/12(m) is required the indicators shall be readable from the conning position. The conning position means centre conning position and is not including the additional conning positions. This is to clarify that it is not necessary to provide an additional rudder angle indicator and a shaft revolution indicator at each additional conning

position in accordance with NK rule, ISO standard and IMO MSC/Circ.982

under the SOLAS Convention.

The above, however, is only the interpretation by ClassNK of the SOLAS regulation.

The regulation does not state that it refers to a conning position on the centreline or

a primary conning position, nor implies secondary or additional conning positions

to which its requirements do not apply. It is also reasonable to interpret that the

requirements that apply to a conning position in the regulation apply to all conning

positions on a ship’s bridge.

The sign indicating the starboard additional conning position on the bridge of

Crimson Mars may have initially prompted the pilot to take this position in the

circumstances. When it became apparent that he could not read, in particular,

the rudder angle indicator he should have moved to a position in which he could

read it. The rudder angle indicator should be readable from a position taken while

conning a ship.

*****

So, as I understand it, the Class NK rules require that if the view through the bridge windows on the centre line is obstructed then two other conning positions with a “clear view” forward must be provided but ClassNK don’t believe that these require the rudder angle indicator to be readable. These secondary positions are indicated on the plan as positions A & E and the Crimson Mars also has these points formally marked with “Conning Pt” in red on the bridge front. SOLAS regulations require that the rudder angle indicator and engine revolution indicator “shall be readable” from a conning position. It therefore seems perfectly clear that the SOLAS regulations require that these two instruments must be readable from the secondary conning positions. However, this would obviously involve additional expense that will bankrupt the poor ship owner so the ATSB are seemingly suggesting that yes, these are the requirements but if the ship’s arrangement is non compliant then it is the pilot’s responsibility to undertake a bridge survey and identify an unofficial conning point where he has both a clear view forward and a view of the relevant instruments! What nonsense. In my opinion such poor ergonomics are totally unacceptable in the 21^st century and a valuable opportunity has been missed by this investigation to condemn such (regrettably all too popular) dysfunctional wheelhouse layouts as not “fit for purpose”.

Although unfamiliar with the Dalrymple port approach the chart indicates that it is a very narrow channel with tricky bends and manoeuvring would seem also to be compromised by the tides mentioned in the report. A small rudder angle repeater probably costs less than 20 and could easily be fitted at the additional conning points. I am in no doubt that had such a repeater been fitted as seemingly required by SOLAS regulations then the pilot would have been monitoring it and this grounding would have been avoided. The old saying of a “ship spoiled for the want of a h’apeth of tar” is, in my opinion, appropriate in this case.

I would like to believe that despite the lack of condemnation by the report, ClassNK and other Classification societies might realise the potential weakness of their arguments, learn the lessons and arrange for additional rudder angle repeaters to be fitted in order to ensure full compliance with SOLAS recommendations at the secondary designated conning positions. However, knowing how such issues are usually dealt with in the maritime world, I wouldn’t be at all surprised if the actual outcome will be for the Classification societies to arrange for the “conning pt” markings to be removed to avoid any potential liability. I hope to be proven wrong!

JCB

USE OF MOBILE PHONES

In the report relevance was attached to the fact that 6 minutes before the grounding the pilot had received a call on his mobile phone which he terminated after 23 seconds. Some publications reporting this grounding have wildly stated that the grounding was caused as a direct result of the mobile phone conversation but the records show that although the call was received just as the ship was approaching an earlier bend in the river, the pilot successfully negotiated that turn and correctly aligned the ship in anticipation of rounding the point where control was lost.. However the investigators did consider the mobile phone use to be of relevance in this case and referred to MGN 299 which includes the following recommendations regarding the potential for watchkeepers to be distracted by mobile phone conversations:

Interference, in this context, relates to the distraction caused by making or

receiving mobile phone calls at inappropriate times during the conduct of

the vessel’s navigation and conning.

Such activity is liable to demand the attention of bridge personnel when

full attention should be devoted to the safe and efficient navigation of the

vessel.

Consideration should also be given to prohibiting all mobile phone usage

when navigational requirements demand the individual attention of all those

responsible for the safe conduct of the vessel.

In this case the phone was used six minutes before the incident for a few seconds. Six minutes is a long time and I personally don’t believe that this call could have possibly have had any influence over the subsequent event but the report makes the following observations:

The pilot did not discuss the use of his mobile telephone with any of the bridge

team. The master stated that its use was inappropriate and that he was not sure if

the pilot was concentrating on the pilotage. The third mate believed that the master,

rather than he, should ‘challenge’ the pilot in such a case. In any event there was no

‘challenge’, increased vigilance, or any other action by the bridge team in response

to the use of the mobile telephone by the pilot.

The pilot stated:

I do not believe that the pilot’s mobile phone use before Salt Pan Point

contributed to the grounding at Long Tom Reef, nor do I believe that discrete

communications by mobile phone after the grounding negatively affected

the return of the vessel to anchor at Bell Bay.

The report responds thus:

While the pilot did not use his mobile telephone when he was giving the helm

orders leading to the grounding, he did so a few minutes before. Using a mobile

telephone causes a distraction and interferes with the attention of the user and

the entire bridge team. This distraction interrupts the thought processes and

concentration of the bridge team and is not restricted to just the periods that a

mobile telephone is used. In any event, there is overwhelming evidence in the

transport industry that the use of a mobile telephone by a person concurrently

with operating a transport vehicle is a distraction to the prime task of operating the

vehicle.

The ATSB investigation report number 162, the grounding of the container ship

Bunga Teratai Satu on 2 November 2000, concluded that the distraction caused

by the use of a mobile telephone was the significant unsafe act that resulted in the

grounding. The incident highlighted the distraction that mobile telephones can

cause to the user, as well as to others.

The use of mobile telephones is contrary to good BRM principles, hinders

situational awareness and prevents an optimal ‘state of the bridge’

You have been warned!! JCB