Bad Pilot, Master Relationship! Passage Plan Deviation Grounds the Vessel

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Summary

On 22 November 2016, at 1357, the Maltese registered bulk carrier Robusto ran aground and remained stranded in the entrance of El Dekheila Channel, Egypt in position 31° 10.18’ N 029° 48.25’ E. The vessel had completed her sea passage from Narvic, Norway, fully loaded with 163,000 metric tonnes of iron ore, with a draught of 17.5 m.

About 15 minutes prior to the grounding, two pilots had boarded the vessel and proceeded to the bridge where the master, third mate and a helmsman were already in the wheelhouse.

General view of the bridge from port and starboard sides

The vessel was proceeding towards the entrance of El Dekheila Channel, following course alternations recommended by the pilot. The pilot’s orders were given directly to the helmsman. The safety investigation revealed that the course recommended by the pilot was different from the one prepared in the passage planning. Moreover, during the navigation of the Channel, the vessel was navigated close to shallow areas, leading to the vessel running aground and remaining stranded. Soundings and subsequent in-water inspections revealed no water ingress in any of the vessel’s double bottom tanks. No injuries were reported.

ECDIS, radar display and helm position and rudder control

Probable Cause

According to MSIU, the immediate cause of the grounding was the vessel’s deviation from the passage plan.

Conclusions

  • Evidence indicated that an adequate passage plan had been prepared and integrated in the ECDIS;
  • Although an adequate passage plan had been prepared and uploaded in ECDIS, the planned approach to the channel was not implemented;
  • The master and the navigational OOW accepted the pilots’ advice, even if it deviated from the agreed passage plan;
  • The presence of two pilots rather than one may have convinced the master that after all, they had better control over the evolving situation;
  • Open and clear communication of risk between the bridge team members was either missing or ineffective;
  • The pilots took a decision without any form of verification – possibly also because they were confident that the ship was outside any hazardous areas;
  • Although the vessel’s deviation from her intended course was seen by the master as a risk that he had to communicate to the pilots, no action was taken to tackle it;
  • The fact that the pilots sounded confident, unconcerned and that they were in good control of the situation, prevented a thorough technical discussion with the other bridge team members;
  • The deviation of the vessel’s course also meant that uncertainty was introduced and the vessel’s exposure to hazards had increased;
  • The crew members forming part of the bridge team did not have access to information on the developing risk;
  • The deactivation of the off-course alarm (i.e., the sound of a physical buzzer) did not help to reinforce the master’s concern that the vessel was off-course;
  • The persons on the bridge had inaccurate knowledge of the situation;
  • Assessment of new information, which was being received on the bridge, was not being done.

GMDSS Station and chart table (with GPS and ECDIS back-up equipment)

Recommendations

MSIU advises TMS Dry Ltd. to conduct a horizontal qualitative research on pilot/master relationship experiences on vessels under its management, analyse the findings, and disseminate the outcome across the fleet.

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Source: Transport Malta