Closed-loop communications are an essential part of good bridge resource management (BRM). In a recent Mars Report, less than adequate BRM allowed for a single point failure and resulted in a ship hitting dolphins. Alcohol abuse was another factor in the incident.
The Mars Reports are compiled (anonymously) by The Nautical Institute to prevent other accidents from happening. A summary of this incident:
A passenger ship was leaving dock in darkness. The master, a pilot and the officer of the watch (OOW) were on the bridge. A tug was secured aft on the starboard quarter. When the lines were clear and under the pilot’s instructions the tug pulled while the Master operated the bow thruster to move the vessel off the berth. Once the vessel was about twenty metres off the berth the pilot requested astern engine and stopped the tug.
A port swing was initiated in order to turn the ship 180 degrees. The tug was initiated again to help with the turn and the master used the bow thruster to port. The pilot then requested ahead propulsion, but the master mistakenly set it to astern instead. The pilot could not see the controller the master was using, nor the RPM or rudder angles. The master, for his part, was operating the RPMs, rudder (one joystick) and bow thruster, and was not repeating the orders in a closed-loop manner.
The OOW warned the master, in a language that was not understood by the pilot, that the propulsion was astern, but the master did not respond. Distances aft were being reported to the bridge by VHF radio, again in a language that was not understood by the pilot. As the vessel gathered sternway, it contacted the dolphins aft.
The investigation found, among other things, that the master’s abilities were probably negatively affected by alcohol consumption.
Advice from The Nautical Institute
- Although the major contributing factor to this accident appears to be alcohol abuse by the master, several other factors conspired to allow the mishap. Had proper BRM been applied, the single point failure of the master may have been avoided.
- The bridge team, including the pilot, should all be on the same page. To accomplish this a plan should be agreed and implemented and a common language used.
- Good BRM requires closed-loop communications.
Mars Reports
This accident was covered in the Mars Reports, originally published as Mars 202019, that are part of Report Number 330. A selection of this Report has also been published in SWZ|Maritime’s May 2020 issue. The Nautical Institute compiles these reports to help prevent maritime accidents. That is why they are also published on SWZ|Maritime’s website.
More reports are needed to keep the scheme interesting and informative. All reports are read only by the Mars coordinator and are treated in the strictest confidence. To submit a report, please use the Mars report form.
