The Marine Accident Investigation Branch has released the investigation report into the collision between ro-ro passenger ferry Red Falcon and moored yacht Greylag.
Summary of the incident
On Sunday 21 October 2018 at 0811, 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 harbour 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 practise 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 manoeuvre 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.
Emergency response
- Once aground, the master ordered the Cowes end anchor to be dropped and alerted
the coastguard. - At about the same time the coastguard received a distress call from the skipper of a nearby yacht and reports of cries for help coming from the fog.
- In response, the coastguard tasked local lifeboats, coast rescue teams and the Cowes
Harbour Commission motor launch to search for persons in the water. - The Cowes harbourmaster later confirmed that there was no one on board Greylag
at the time of the collision and that a family on a nearby yacht was safe and well. - As a result, the search was called off shortly after 1000.
- Red Falcon was manoeuvred to the East Cowes ferry terminal with the aid of a local tug, where all the passengers and vehicles were discharged.
- The master and C/O were both breathalysed, with negative results.
- At 1345, following an inspection by a Maritime and Coastguard Agency (MCA) surveyor, Red Falcon left Cowes and returned to Southampton.
- A dive survey carried out in Southampton found no damage to the vessel’s hull or its propulsion system. Red Falcon returned to service the following morning.
Safety management
Red Funnel voluntarily complied with the International Safety Management Code (ISM Code), which exceeded statutory requirements for domestic passenger ferries. The company safety management system (SMS) contained operations procedures
for daily shipboard work routines.
The ISM Code section 1.2 states that:
- Safety management objectives of the Company should assess all identified risks to its ships, personnel and the environment and establish appropriate safeguards.
- Red Funnel had identified risks as required by the ISM Code and this formed part of its SMS.
- Its risk assessment entitled ‘Navigation in Restricted Visibility – Raptors’, stated that:
- Navigation in restricted visibility is one of the most high-risk operational tasks that we incur.
- A full appreciation of all aspects of the potential hazards needs to be fully adhered to by all involved.
- Navigating a ship in restricted visibility requires a full understanding of the COLREGS4, in particular.
Safety Issues to be addressed
- 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 practised 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.
- There was 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 harbour 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 practised in their respective roles, and able to react quickly when the need arose.
Actions taken
The MAIB has contracted Greenstreet Berman Ltd to undertake an ergonomic assessment of the equipment and control layout of the wheelhouse on board Red Falcon, and a human factors study of the actions and activities undertaken by the staff involved in the accident.
Red Funnel has:
- Undertaken its own internal investigation and has shared its report findings with Cowes Harbour Commission.
- Implemented a new navigation procedure, which includes an assessment of helmsman competence, regular frequent practice steering through Cowes Harbour and regular practice at steering by compass alone.
- Amended its blind pilotage routine to include rotation of ratings’ duties and more accurate detailed recording of drill composition within its training management system.
- Reviewed the content of its bridge resource management training programme, increased its length to 2 days, included emergency scenarios and has involved deck officers, engineers and ratings.
- Commenced regular navigation assessments of vessel operations, which includes the implementation of resource management techniques. In addition, several shore management team members have undertaken navigation assessment training.
- Included ratings and engineers in company crew resource management training.
- Joined an industry crew resource management group at the United Kingdom Chamber of Shipping for the purpose of developing and implementing best practice.
- Amended the company ship-handling training for C/Os, to include aspects of anticipated vessel operations and the practising of emergency scenarios.
- Adjusted the positioning of the radar units on all ‘Raptor’ class vessels so that they are more visible to the person conning the vessel from the side of the forward and aft manoeuvring consoles.
- Installed voice recording capability to the wheelhouse of all ‘Raptor’ class
vessels.
Recommendations
Red Funnel is recommended to:
- 2020/110 Conduct regular assessment of ship-handling capabilities of masters and C/Os, not limited solely to normal operational routines of berthing an unberthing, including pilotage by instruments alone.
- 2020/111 Review the method of determining the orientation of the vessel displayed on the ship’s electronic chart system, to ensure that the system is not solely reliant on the operation of a toggle switch and that there is a method of positive confirmation of the orientation displayed at each manoeuvring console.
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Source: Gov.UK
