Gard News 207, August/October 2012
Gard's claims handlers see a large number of claims every day and although these may vary a lot in nature and size, from small petty claims to very serious ones, there are common features present in them that may be worthy of some reflection.
It is no secret among claims executives that in claims of all sizes and types certain common features can usually be observed:
1. The lion's share of claims can be attributed to human error of some sort.
2. Claims caused by human error occur in spite of what seems to be adequate efforts by operators to prevent them, i.e., management and quality systems.
3. The largest claims are sometimes those which can most clearly be attributed to human error.
Some practical cases can serve to illustrate how the human element plays a role in claims. This article describes a few examples taken from real incidents, involving high-quality managers and owners who have strong focus on quality management, which will probably be of interest to readers.
Collision and grounding
A loaded chemical tanker of about 5,000 TDW is inward-bound on a river. The river is navigable by a deep-water channel about 500 m wide and clearly marked with light buoys, with mud banks on each side. The river is covered by Vessel Traffic System (VTS) and pilotage is mandatory. The vessel is about midway in the six-hour passage from pilot station to berth. Fog is limiting visibility to some two cables (365 m), which is roughly three times the vessel's length. The vessel is proceeding at 10 knots and the pilot is giving rudder orders varying between rudder angles and courses.
The second officer is on look-out and stand-by duty on the engine telegraph and is also monitoring the helmsman making sure the pilot's rudder and course orders are followed. The pilot relies to a large extent on the radar in his navigation. The chief officer, who has the navigation watch, and the master are at the back of the bridge discussing the upcoming port call and plans for rotation of discharging, tank cleaning and loading. They are in for a busy two days at the port.
So far so good, but the trouble starts when the second officer makes the pilot aware of a green buoy on the port bow, which should have been to starboard. At the same time there is a large echo on the radar further ahead on the port bow, which obviously indicates a large vessel on an opposite course. The second officer observes that the pilot gets very nervous as he gives a rudder order to port, which eventually leaves the green buoy on the starboard bow, but also the large echo on the radar. Now the situation is picked up by the master and the chief officer and they ask the pilot what is going on. The pilot replies that he made a mistake about the position in the river. The master gets nervous about the approaching vessel appearing on the radar, which is now also physically visible. The master orders full ahead and hard to starboard, which is immediately executed. At this point the VTS also picks up on the situation and calls the vessel on the VHF. As the vessel makes a sharp turn to starboard, its port quarter makes contact with the bow of the approaching container vessel and then steers directly against the riverbank where it runs aground before the officers on the bridge are able to correct the course and reduce speed.
What actually happened in the case described above was that the pilot misinterpreted the radar and thought that the bend in the river was further ahead than it actually was. Suddenly realising his mistake, he panicked and gave a hard to port rudder order so as to avoid grounding, but disregarding the approaching vessel ahead. It was later found that stopping the engine and performing an easier port rudder manoeuvre would have led the vessel to pass the meeting vessel port to port and well clear of the riverbank to starboard.
It is probable that had the vessel's officers on the bridge taken a more active part in the navigation of the vessel during that particular passage then:
a) they would have realised the potential danger of the situation sooner and would have corrected the pilot in time to prevent a dangerous situation, or
b) they would have intervened and taken more adequate steps when it was obvious that the pilot had erred and panicked.
There are unfortunately a number of claims which seem to be attributed to the master and the OOW (officer of the watch) relying too much on the pilot and not monitoring and questioning his instructions. The pilot is only an advisor and guide to the OOW and the responsibility and liability for the navigation and manoeuvring of the vessel rest with the master and the OOW even when the pilot is on the bridge.
A vessel is under way on an ocean crossing with course set out from start to end. The course is set out and the voyage planned on a small scale planning chart. The course is set to pass some small groups of mid-ocean islands and the CPA (Closest Point of Approach) is considered and thought to be well on the safe side. On a nice tropical night with calm seas and good visibility, the vessel makes its approach to pass one group of islands well on the port side some time after midnight.
The chief officer observes during the last two hours of his 1600-2000 hrs watch that a slight breeze and current are working together to set the vessel slightly off course and towards the islands ahead. He therefore makes a correction to the course to compensate for the drift and setting to keep the vessel on its intended course. When handing over the watch at 2000 hrs, the chief officer makes the second officer aware of this.
The second officer continues to plot the positions throughout his watch and observes that the vessel is still drifting somewhat off course to the effect of making the CPA to the islands ahead less safe than planned. He therefore makes some minor course adjustments to compensate for drift and setting. At midnight the watch is handed over to the first officer, who is also made aware of the drift and the course adjustments. At 0040 hrs the vessel runs aground at full speed on the beach of a small low atoll. The beach is mainly sand and pebbles and slopes at a low angle into the sea so the vessel suffers minor damage but can not be re-floated with its own power. A costly salvage operation follows.
The positions were plotted in the same small scale planning chart covering the entire ocean where the voyage was planned and the course set out. In a small scale chart it is difficult to accurately measure small distances and observe small deviations from the course between hourly plots. The reason for using a small scale chart was probably that it was not considered necessary to conduct "millimetre" navigation when crossing the ocean. The island on which the vessel grounded was marked on the chart in use, but only as a small dot and the course was set to pass at what seemed to be a safe distance.
The drift and current, however, worked together to set the vessel off course towards the island and it is painfully obvious that the corrective actions taken by the navigation officers were not adequate.
It can be concluded that the grounding would not have happened if:
a) a large scale chart had been used for position plotting since it would then have become apparent that the course was heading gradually towards the island, and/or
b) a much wider passing had been planned in the first place, and/or
c) a considerable safety margin had been applied when the corrections were made to compensate for drift and setting.
It is also possible that proper look-out and use of radar could have been an issue. On the other hand, the island was very low and it is arguable that it could not have been spotted visually in time in the dark tropical night. It is unclear whether and why the island was not seen on the radar, but it is a known fact that radars are subject to a lot of interference in tropical waters and it could be that both the rain and sea clutter settings had been adjusted to deal with that, thus at the same time removing or diminishing the radar image of the island.
The above examples focus on navigation, which is possibly where one sees most clearly the impact of the human element. There are, however, a number of other claims types where the human element is often seen to play a significant role.
In some claims of a more technical nature sometimes shortcuts and omissions in maintenance and operation have consequences such as engine breakdowns, in some cases followed by groundings or collisions.
One issue that springs to mind is the recommendations for fuel treatment that come with the analysis reports of fuel, which in some claims are not adhered to. This can result in complex and technically difficult claims to deal with.
Human error may also play a role in more tragic cases, such as explosions and fires, often with severe injuries and even fatal consequences. The classic example is where a hot work permit is given for a specific location on board a tanker in ballast and, after conclusion of the relevant welding work, it is decided on the spot that while they are at it, they will also do some minor welding work in another location, which is not covered by the hot work permit. The result is a big explosion and loss of lives and major damage to the vessel.
The above examples are not unique. The list goes on, with a number of small and large cases within all claims segments apparently caused by lack of attention and/or lax attitude to standards of safe operation.
Much has been written and said about safety culture and the crux of the problem can probably be summed up as doing the right thing at the right time, firstly preventing and then responding to minor and major incidents with potential for damage to life, environment and property.
Operation of ships is full of regulations, instructions and guidelines which officers and crew are expected to know and adhere to. The ISM Code has to a large extent codified what is known as good seamanship. A culture of safety may perhaps be achieved through written instructions, but in the end it is a question of a common mind-set throughout the organisation. Management ashore and on board need not only ensure that the formal skills are in place but also ensure, encourage and inspire the necessary attitudes to achieve the safety objectives. Statistics prove beyond doubt that investing in a good safety culture provides results and pays off in the long term. It is the lack of a safety culture that is costly, not safety itself.
Any comments on this article can be e-mailed to the Gard News Editorial Team.