This report from the Transport Accident Investigation Commission New Zealand features the investigation into how a 12,596gt passenger freight ferry failed to make a programmed course alteration while in automatic steering, during the approach to a narrow channel.
The report identifies a number of Human element related safety issues including: the adequacy of bridge resource management; the adequacy of training in the use of all integrated bridge systems; the adequacy of contingency planning for safety-critical situations on board; and the adequacy of procedures covering the dissemination of information from the International Maritime Organization.
The ship was being steered automatically on a pre-determined route by way of the Automatic Navigation and Track Steering (ANTS) system. The master was on the bridge, but the mate had the con. The ship did not make a planned automatic turn to port and recovery from the situation required swift intervention by the bridge team to initiate the turn manually and prevent the ship grounding. The report concludes that the ARPA radar navigation system probably defaulted from the ANTS mode to autopilot mode without the change being noticed by the mate or master.
There were a number of reasons for the system to default to autopilot mode: it may have received an erroneous signal from an external input such as the DGPS due to aerial masking or incorrect differential signal reception; it may have received such conflicting information from the ground and water speeds of the Doppler log that the information was discarded as erroneous; or the parameters for the off-track jump limit
The ship was fitted with an Integrated Bridge System (IBS), which complied with international standards and IMO guidelines. The manufacturer ran courses on its IBS, and the original crew had received training in its use prior to the commissioning of the ship, some 6 years
previously. But, training for the master and the mate in the operation of the IBS and of the ANTS consisted of 2 weeks ‘hands-on’ familiarization on board while the ship was in service, given by other officers experienced in the use of that equipment.
At the time of the incident, the ship owner did not have a dedicated person ashore dealing with training of sea staff in the use of the IBS, nor did it have any formalized policy to carry out this training to the standard recommended by IMO in MSC/Circular 1061 – Guidance for the operational use of integrated bridge systems. This Circular recommends that shipping companies establish training programme for all officers with operational duties involving IBS.
The report also highlights: deficiencies in the ergonomics of the bridge design; poor situational awareness on the part of the mate; the risk of ‘routinisation’ of the passage occurring; and that neither the master nor the mate had ensured that a helmsman was standing by to take over the manual steering immediately as required by the local navigation by laws.