The accident report released by Marine Accident Investigation Branch analyzes the collision between ro-ro passenger ferry Red Falcon and the moored yacht Greylag.
Summary of the Incident
On Sunday 21 October 2018 at 08:11, the roll-on roll-off passenger ferry Red Falcon collided with and sank the yacht Greylag, which was on its mooring in Cowes Harbour, while the visibility within the harbor was severely reduced by fog.
Red Falcon subsequently passed through the yacht moorings and ran aground in soft mud. Red Falcon was re-floated later that morning having suffered no damage. There were no injuries sustained to passengers or crew and no pollution. The yacht Greylag was a constructive total loss. After entering Cowes Harbour the visibility had reduced and the helmsman experienced difficulty steering due to the lack of visual references and his lack of practice steering by digital compass alone into Cowes Harbour.
This led to the master taking over control and operating the steering and propulsion himself. Critically, the role of keeping oversight of operations was then lost. The poor visibility required the master to rely totally upon his instrumentation. His lack of practice using instruments alone to maneuver the ferry resulted in over-correction of steering, which led to the vessel swinging to port out of the channel, ultimately turning through 220º.
The subsequent collision and grounding occurred because the master lost his orientation in the fog and drove the ferry in the wrong direction. He became disorientated because he was suffering from cognitive overload due to high stress, lack of visibility, bridge equipment ergonomics, and the breakdown of support from the bridge team.
The master’s actions and the lack of communication of his intent resulted in the members of the bridge team becoming disengaged, and this led to an absence of any challenge to the master’s decisions. Following its own investigations, Red Funnel has taken steps to improve its management processes, equipment, and training routines, and Cowes Harbour Commission has undertaken a review of its aids to navigation and risk assessments.
Recommendations aimed at reducing the likelihood of future collisions and risks to harbor users have been made to Red Funnel, Cowes Harbour Commission, and Cowes Yacht Haven.
Safety Management and Risk Assessments
CHC operated an SMS based on the UK government Department for Transport’s Port Marine Safety Code (PMSC). To comply with the PMSC, port authorities had to:
- Ensure all risks are formally assessed and as low as reasonably practicable in accordance with good practice.
- Operate an effective marine SMS that has been developed after consultation and uses formal risk assessment.
- Use competent people (i.e. trained, qualified, and experienced) in positions of responsibility for the safety of navigation.
Bridge Resource Management
Effective BRM requires the efficient use of all available resources, both human and electronic, but is dependent upon several factors. These include:
- Each team member fully understanding their role.
- All team members being fully aware of the passage plan and having a dynamic awareness of any changes.
- Good information exchange and pro-active communication.
- All team members being empowered to seek clarification and to challenge where necessary.
- Best use of electronic navigation aids.
Safety Issues Directly Contributing To The Accident
- The collision and grounding occurred because the master became disorientated in the fog and inadvertently drove the ferry in the wrong direction.
- The helmsman was inexperienced at steering the vessel into Cowes Harbour and was insufficiently practiced at steering by digital compass alone.
- When the master took over operating the controls, the oversight of operations was lost, the members of the bridge team started to act in isolation and did not adequately support the master.
- The ergonomic layout of the navigation equipment did not support the single-person operation of the ship’s controls from the side of the console.
- With no visual references, the master experienced significant difficulty in controlling Red Falcon and was fortunate not to hit the marina wall, yachts, or navigation marks in the vicinity.
- The master fixated on the ECS and VSP controls due to high task load and levels of stress. This, compounded by the lack of visibility and the breakdown of bridge team support resulted in him becoming disorientated.
- The electronic chart system relied on a manual switch to provide heading information, which was not operated by the master as he rushed between the Cowes and Southampton ends.
- The master became focused on the ECS and used the information displayed to drive his decision-making. The erroneous heading information being displayed supported the master’s belief that he was driving Red Falcon back into the channel.
- The actions of the master and the lack of communications of his intent, resulted in the bridge team becoming disengaged, and not supporting the master adequately.
- A rapid deterioration in visibility in the harbor after a ferry had entered the channel was unusual, but not unforeseeable.
- Emergency training for such a scenario would have helped ensure that all members of the bridge team were familiar with and practiced in their respective roles, and able to react quickly when the need arose.
Other Safety Issues Directly Contributing To The Accident
- The inherent limited directional stability of Red Falcon’s hull form, coupled with tidal stream effects, master’s frequent course orders, and the lack of visual references, led to the helmsman struggling to maintain the ship’s heading.
- The poor visibility removed the visual confirmation of the vessel’s position and orientation, causing the master to rely on instrumentation and greater input from the bridge team.
- The C/O became confused, mentally rejected the picture displayed by the radar, and believed the ECS display instead. In the circumstances, he did not have sufficient time to re-evaluate the ferry’s position, and, therefore, did not challenge the master’s actions.
- The lookouts, helmsman, and C/O had been involved in recent incidents that might have affected their confidence. The C/O had only just returned to work following suspension and had little experience working with the master, who was acting in a temporary role.
Safety Issues Not Directly Contributing To The Accident
- The blind pilotage training records did not identify the roles undertaken by any of the three-deck crew during the periods of training.
- The roles of individual bridge team members were not sufficiently detailed within the company’s reduced visibility procedures.
- Cowes Yacht Haven did not have a comprehensive suite of risk assessments that included the hazard of a collision between commercial vessels and raft of yachts on its outer pontoons.
- The hazard to people sleeping on yachts in Cowes Harbour had not been sufficiently considered, documented, or mitigated within risk assessments produced by Cowes Harbour Commission, Shepards Wharf Marina, or Cowes Yacht Haven.
Safety Issues To Be Learned From The Incident
- The master became fixated upon the information displayed on his electronic chart and operating engine controls, ignored information displayed on other electronic equipment, and became cognitively overloaded due to high stress.
- The bridge team became disengaged from the operation due to a lack of clear communications and emergency scenario training.
- The hazards to people sleeping on yachts in Cowes Harbour had not been sufficiently mitigated within risk assessments.
Recommendations
Red Funnel has been recommended (2020/110 and 2020/111) to conduct regular assessment of ship-handling capabilities including pilotage by instruments alone, and to review the shipboard method of determining orientation displayed on the ship’s electronic charting system.
The Cowes Harbour Commission and the Cowes Yacht Haven have been recommended (2020/112 and 2020/113 respectively) to review their risk assessments for the collision between a commercial vessel and raft of yachts moored at their marinas detailing mitigating measures that are within their control to implement.
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Source: Gov.UK
