General Cargo Ship Grounding Due to Inaccurate Positioning – Investigation Report

This investigation report refers to the grounding of a general cargo ship caused by the inaccurate positioning of the vessel. On 12 October 2010 at 22:30 the Netherlands-flagged MS NORDLAND, in ballast condition, departed Turku for Pietarsaari. The master, a pilot and a lookout were on the bridge. However, immediately prior to the accident the lookout was not on the bridge.

2014.04.07 - Grounding Due to Inaccurate Positioning - Investigation Report Figure 1

The ship’s joystick hand steering was used as the vessel cast off and only later, on the fairway, was the ship’s autopilot switched on. The pilot used the ship’s only radar. No suitable electronic navigational charts for the voyage were available. The autopilot settings were as follows: ROT° Min 20, Off Course 20°, Rudder limit 20°, Yawing 1, Rudder 4 and Cnt. Rudder 5.

While the pilot independently steered the vessel the master monitored the passage on his own computer and paper chart. This was done in complete silence. No communication ensued when the vessel approached wheel over points (WOP). The pilot kept adjusting the course without in-forming the master of his decisions.

2014.04.07 - Grounding Due to Inaccurate Positioning - Investigation Report Figure 2

The wheelhouse of MS NORDLAND as well as the positions of the master before the the accident and the pilot at the time of the accident.

Upon approaching the Rönngrund narrows the course over ground (COG) was 268°. At 00:02, abeam of Östra Långgrundet island, 0.25 NM from it, the pilot first set the autopilot heading to 300°, followed by 324° and then 335°. When he noticed that the turn could not be completed as he had planned, and that the radar return of the east spar buoy was lost in sea-clutter, he requested the use of hand steering.

By the light of a torch the master located the rudder control button and engaged the joystick hand steering, which the pilot then commenced to use. At this point the vessel was in the red sector of Rönngrund, on a 310° COG. The pilot turned the steer-ing 20° to starboard, which increased the rate of turn (ROT) to 54°/min. Soon after this the pilot placed the rudder amidships. Right then, at 00:07 and at the heading of 338°, the vessel ran aground between Paukut and Hopialuoto islands at 60°16.2’N 021°47.2’E.

2014.04.07 - Grounding Due to Inaccurate Positioning - Investigation Report Figure 3

Damage to the port side of the bow.

Root Causes

  1. Shortcomings could be detected in the implementation of the Safety Manage-ment System on the vessel due to inadequate compliance with regulations. When the vessel is at sea the master is responsible for its implementation.
  2. The company/vessel had yet to start risk assessment.
  3. The recommendations of the IMO and the maritime industry were not sufficiently utilised in bridge resource management or voyage planning.
  4. The voyage plan did not fully comply with company guidelines.
  5. The pilot’s passage plan did not appropriately take advantage of the fairway area.
  6. The condition of the navigational equipment on the bridge did not support being able to work normally.
  7. The autopilot settings were poorly suited for navigation in the archipelago.
  8. The voyage was started without a clear delegation of authority.
  9. The pilot and the master did not brief each other about the voyage plan prior to unberthing.
  10. For the most part, navigation was based on the pilot’s autonomous performance.
  11. There was inadequate communication during the voyage.
  12. The workload almost entirely centred on the pilot.
  13. Sea-clutter made it more difficult to observe objects on the radar display.
  14. The turn was wider than normal prior to the grounding.
  15. Full speed was used at a challenging spot.
  16. There was no lookout during the moments preceding the accident.
  17. There was a loss of situational awareness before the grounding.
  18. Desperate last-minute steering inputs ensued before the grounding.
  19. Imperfect implementation of the safety management system and as a result, an inadequate voyage plan and/or its efficient monitoring.
  20. Almost nonexistent, bridge resource management (BRM), which promotes the safe navigation of a vessel. It can be seen that the ones responsible for navigation want to operate within their so-called ‘comfort zones’. Apparently, the IMO’s voyage planning recommendation Res.A893(21) is considered to be impractical because it is laborious. It includes a number of issues that must be taken into consideration. Most groundings in the archipelago have occurred during turns. Hence, turn planning which allows for the vessel’s turning radius and speed is one the aforementioned recommendation’s key aspects. If autopilot steering is being used in turns, its settings must be suitable for archipelago navigation at the beginning of and during the voyage.

Lessons learned

  • Application of bridge resource management in such a manner that the ship’s crew and the pilot share a common view on the voyage plan and its implementation as well as the use of steering controls and the steering manoeuvres to be executed.

Source: Finland Safety Investigation Authority

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