All Available Means
A look into a marine accident can give us insight into our own operation.
Every day we try to do things right by following company procedure, keeping safety at the forefront and working smartly. Safety meetings are held; "Prior to evolution" meetings happen at the start of each watch. From the shore, various types of audits are normal parts of our business these days.
But beneath all the good things that we do, can a sense of complacency set in?
The notion that we are doing it all right and that our operations are in compliance can mask problems underneath what is normally shiny exterior.
To illustrate, let's look at the case of the M/V DELTA MARINER.
The National Transportation Safety Board (NTSB) last week reported their findings from the investigation of the allusion of the M/V DELTA MARINER and the Eggner's Ferry Bridge in January, 2012.
To refresh your memory, here is a synopsis of what happened from the NTSB report:
In the evening of January 26, 2012, the M/V DELTA MARINER, while southbound on the Tennessee River at mi 41.7, allided with the partially lit Eggner's Ferry Bridge. The M/V DELTA MARINER is a 312 ft. ocean going ship that is designed to operate with a shallow draft on the inland waterways and western rivers.
The ship attempted to pass through the lowest of four navigable spans of the bridge at a speed of 11.5 mph. As a result, a 322-foot span of the bridge, including a portion of U.S. Highway 68, was torn away. The vessel sustained minor damage to its bow area, but its cargo of a NASA rocket engine was undamaged.
How did this happen? There was blame to go all around in this accident, but ultimately responsibility for safe navigation rests with the operator.
Let's look at the details and see how they can apply to our operation.
Aids to navigation.....The Eggner's Ferry Bridge has four navigable spans. Red lights mark piers and supports, green lights indicate the navigable waterway's centerline, and three vertical white lights signify a preferred channel marked with red and green channel lights. On that night, only the span to the far right had the required red and green span lights working. The three vertical white lights marking the main channel were out along with the red/greens on three of the navigable spans. The Kentucky Transportation Cabinet, the owner of the bridge, failed to maintain the required lighting and did not effectively respond to reoccurring problems with the lights. The personnel repairing the ongoing problems did not understand the correct lighting configuration and the main span vertical white lights had been out for over a year.
OUR LESSON......When you come across problems with aids to navigation, report, report, report! Even if you have reported the same problem in the past, another report can only help get it fixed. Be the squeaky wheel to get the problem resolved.
Wheelhouse team...... In the wheelhouse on the night of the accident was a large support team. The Captain, the Chief Mate, the Third Mate and an AB were all present in the wheelhouse. A Trip Pilot was also present advising the Chief Mate with local knowledge. The group focused exclusively on the few lights visible on the bridge while ignoring their chart plotter and radar which would have given them critical information on their position in the channel and the proper lighting scheme. Ignoring easily available information, the Trip Pilot continued to direct the vessel toward the span that was too low for the Delta Mariner. There was no definitive follow-up action by the rest of the group in the Wheelhouse when the Trip Pilot indicated uncertainty on the lights. There was discussion by the crew, but no action.
A voyage plan was developed by the crew prior the trip, but it lacked critical information and it lacked any updates as the trip progressed. A broadcast "Notice to Mariners" highlighting the lighting problems went out twice a day in the area via Channel 16. The crew failed to pick up on it.
OUR LESSON....Use all wheelhouse resources. As per Rule 5 of the Navigation Rules, to make a full appraisal of a situation, all appropriate means must be used. Beyond the obvious wheelhouse resources, additional information such as "Notice to Mariner" and local discussion with in the area boats should be used. ..... Also as per the Higman Safety Management System, during any bridge transit, an additional lookout is required. The additional lookout's job is to assist the wheelman on watch with observations throughout the entire bridge transit.
| Capt Mike Serrette works the rough log. |
A voyage plan should be a "living document" that is consulted and updated throughout the trip. A boiler plate voyage plan that becomes a routine chore is not worth the effort. Spend the time to create a usable plan that actually can be used and provides the wheelman on watch with real time information. This means doing a bit of research before the voyage begins and may mean updating as the voyage progresses.
Listen for broadcast "Notice to Mariners" and pass on to the next watch. That message to switch to channel 22A may not offer new information most of the time, but there may be that one time when you miss critical navigation information.
Company Safety Management System..... The NTSB concluded that the Delta Mariner's parent company, although they had a Safety Management System for over ten years, failed to effectively implement it. Because of the good safety record of the Delta Mariner and the overall experience of the well trained crew, the parent company was complacent regarding the safety of the vessel's operations.
OUR LESSON.... A good Safety Management System only works when all are onboard, both crew and shore staff, with the implementation and the administration. Good ideas poorly implemented and overseen can actually detract from safety. Though audits, safety reviews and SIRE inspections may seem burdensome, they can help us all stay on track with our plan. Review the Higman Safety Management System on a regular basis and make sure all are true to the plan.
The absence of negative feedback can detract from safety. We never look forward to negative feedback, but a less than perfect checkup can keep us on top of our game. Constructive criticism is the key word here and its use can keep all cewmembers on task.
Conclusions.....Incidents do happen. A proper investigation with a well thought out conclusion is a valuable tool to help us look critically at our operations. Before we pat ourselves on the back for a top notch operation, let's make sure it is top notch all the way through. |