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Gard News 193, February/April 2009

"What if...?" – Planning for the unexpected before an emergency develops

We plan very well for situations which we know will cause us problems. The situations which we tend not to plan for very well, and which therefore catch us by surprise, are those where the potential for harm has not been foreseen or is considered too remote.

Things could have been different for over 1500 people who lost their lives in that incident if the master and officers of the TITANIC had asked themselves (amongst other things): “what if the ice has progressed further south so as to affect our intended course?”.

In today’s busy world, especially on ships, there is little time to stop and think about potential problems, to ask “what if…?”. There are response plans and checklists available for emergency situations which have the clear potential to cause the crew and ship harm – for example, steering gear failure and fire. However, many serious incidents start life when there is no emergency as such, and develop into emergencies because the potential for harm has not been foreseen or has been considered too remote. Instead of asking ourselves “what if…?” we tend to persuade ourselves that something bad will not happen. In the wider context, asking “what if…?” is very much a part of situational awareness. The development of bridge resource management has done much to address deficiencies in situational awareness, by stressing the importance of a team approach. However, if the members of a team are too preoccupied with tasks at hand, or other human factors (such as fatigue) are at play, there will be a much greater chance of potential emergencies (or “what ifs…?”) not being considered at all.

What if…? –  The weather
There is a lot of current debate about climate change and storms which are more severe or sudden than forecast. Claims experience, however, suggests that in many cases the crew simply underestimates the effects of weather on the ship. A case mentioned in a recent UK investigation report serves as a useful example. A tanker was in ballast (riding high) and dragged its anchor across a gas pipeline in bad weather. The report concluded that the master chose to remain at the anchorage despite it not being a recommended anchorage in the circumstances and despite deteriorating (but forecast) weather conditions, which increased the potential risk of windlass failure. Such failure did indeed occur due to shock loading and the crew were unable to slip the anchor due to tension on the bitter end. Had the master considered the potential problems (i.e., the “what ifs…?”), he would probably have left the anchorage and rode out the storm. Another recent case was the subject of an investigation by the Australian authorities, who found that the master did not appropriately ballast the vessel and did not weigh anchor until it dragged in very bad (but forecast) weather. The investigation report went on to find the master had incorrectly assumed that the port authority would instruct ships to put out to sea when conditions were bad – he probably did not ask himself  “what if they do not, and what if my anchor does not hold?”.

The obvious common factor in these two incidents is that both vessels were at anchor. In contrast to cases where vessels have been caught out by bad weather when alongside a berth and when the ship’s crew will often be very busy, these two cases suggest that potentially dangerous scenarios are simply being overlooked, even during the more relaxed (perhaps too relaxed) periods when at anchor.

What if…? – Pilot error
Pilot error is probably not the first thought to come to mind when a pilot walks onto the bridge. Perhaps it should be – they are not expected to make mistakes, but they do. A recent five-year study of claims in excess of USD 100,000 recorded by each of the Clubs in the International Group of P&I Clubs revealed that some 262 claims were caused by pilot error, with an average cost per incident of USD 850,000.1 Several cases from Gard’s claim files have been previously featured in Gard News.2  In a recent case, the shipowners’ dock damage liability resulted in a payout of several million dollars. The case involved the berthing of a partly laden VLCC. The vessel had three tugs, the tide was slack and the wind light. However, one of the two pilots was in his final phase of training for the ship type/berth and he had the control of the vessel. It was night and the shore Doppler readout was not working. The approach speeds, angles and bow/stern distances were therefore communicated to the pilot by VHF (one can imagine the difficulty). The vessel was not brought under control before she made her final approach to berth and investigation suggests that she exceeded the maximum angle (three degrees) and speed (21 ft/minute) of approach, making contact at about six degrees and a speed of 60 feet/minute (which interestingly increases the berthing force by a factor of nine). Insurers often do not get to hear about cases where the master intervened and stopped the pilot, aborted the approach and started again. Of course, it is a difficult situation for masters, but there is a need to be decisive, especially since it is he and the owners who are most likely to bear the brunt of the consequences of a pilot error. It should be kept in mind that the master is in command of the vessel's navigation at all times with only one exception: when transiting through the Panama Canal.

A United States Coast Guard investigation report into the grounding of a bulk carrier serves as a good example of the need to be strong when a pilot has the control of the vessel. The report concluded that the pilot, who failed to give a helm order at a turn in a channel, asserted his responsibility on the bridge by refusing to honour the master’s request to sign the pilot exchange card. The report went on to say that the pilot’s authoritative presence on the bridge created an atmosphere wherein the mate did not feel he could “speak up” or “challenge” the decision of the pilot.

What if …? – Risk of collision
Asking “what if…?” where there is a risk of collision should be natural for the bridge watch-keeper. Unfortunately, the growing number of navigational accidents suggests that this is not the case. In a recent incident it was fortunate that both crews escaped unharmed and that there was minimal pollution. However, one of the vessels was badly damaged and foundered, requiring an expensive salvage operation of ship and cargo. The incident is described in Image 1, below.

In Image 1 the two vessels are seen approaching each other in a routing scheme. Vessel A is heading south and vessel B is heading north-east. Both are roughly following the route as depicted by purple wavy lines, which meet south-east of a buoy marking the westerly edge of the route. The intention of vessel A was to alter to starboard at the buoy to follow route X as opposed to route Y. Unfortunately, vessel B was not sure which route vessel A intended to follow. As the vessels closed, vessel A altered course to starboard as intended and very shortly after that vessel B altered course to port. The incident resulted in insurance claims totalling in excess of USD 20 million and perhaps it could have been avoided had the bridge team on vessel B asked themselves “what if vessel A intends to alter to starboard to route X rather than carrying straight on to follow route Y?” and the bridge team on vessel A asked themselves “what if my intentions (in terms of which route I intend to take) are unclear?”. The investigation into the incident concluded that neither vessel made timely contact with the other to arrange for a safe passage.

The above collision was one in which both vessels had plenty of time to react, but that may not always be the case. In another collision case investigated by the Danish authorities, the vessels were passing on reciprocal courses in a one mile wide deep water route. One of the vessels suffered a steering failure at the moment of passing and even the double hull of the other vessel, a tanker, could not prevent a large spill of fuel oil from one of her cargo tanks. What could the tanker have possibly done? The investigation report concluded that a contributing factor was the decision of both vessels to use the route, when there was a note on chart saying that the route should only be used by ships which, because of their draft, are unable to safely navigate outside. By using the route, the closest point of approach (CPA) between the vessels was considerably less than if they had used the recommended direction of traffic flow and the available time for evasive action considerably reduced.

What if …? – Repairs at sea
If recent media reports are to be believed, many incidents today involve damage to engines, often on board new ships, indicating that machinery systems are not becoming more reliable. Any vessel with an engine problem, especially a new and expensive one close to the shore, generates a certain level of concern. Even vessels that at first find themselves far off land in no immediate danger can end up perilously close when repairs do not progress as expected. In some cases repairs carried out by crew are unsuccessful and external assistance is called in to save the day. In others assistance is not called for or does not arrive in time and vessels find themselves in trouble. A classic example of the latter was featured in an article in Gard News issue No. 1813 in a case where the chief engineer’s optimism as to when repairs would be successfully completed was shared by the master for too long. When the master finally sought external assistance there were no vessels or tugs available in the area that could possibly reach the vessel in time. The vessel grounded and became a total loss, luckily without loss of life.

A multitude of “what if …?” questions arise and ought to be considered in such cases, quite apart from the obvious one as to when external assistance can reach the ship. For example, what if the engine fault has been wrongly diagnosed, what if the wrong spare part is on board, what if someone gets injured during the repair? 

A very tragic case of another vessel grounding after unsuccessful repairs was the subject of an investigation by the US authorities. The vessel found itself in extremely bad weather in a very remote part of the world and several crew members died during evacuation from the vessel. Soon after the engine failure the ship’s superintendent was called by the master and told that the vessel was in no immediate danger or close to land (she was 46 nautical miles from the closest point of land – an island). The superintendent agreed with the proposed action to repair the engine, but it soon became apparent that external assistance would be necessary. The first tug arrived some 30 hours after the engine had failed, by which time engine repairs had been stopped due to the danger posed to the crew by the extremely rough weather.  A second tug arrived ten hours later, but never connected a line, and after a further three hours the first tug’s line had parted. The weather prevented other attempts to connect tow lines and, despite the use of the vessel’s anchor as she approached shallower water, she eventually grounded some 53 hours after the engine had initially failed.

It is perhaps questionable whether, in this case, a state of emergency existed at the time the engine failed, particularly given the remote location and bad weather. Either way, asking “what if …?” at that moment might have bought some extra time.

Planning for the unexpected – Problems
How do you plan for something you do not foresee happening? Often there is no checklist or response plan specific to each exact situation and it is impractical to produce checklists and plans for every eventuality, every “what if …?”. Indeed, checklists can be dangerous because they may omit to refer to crucial considerations specific to the circumstances. Perhaps at the end of every checklist the question “have you considered other eventualities?” should be added.

Another problem is that sometimes there may be very little time to take action, and that is particularly relevant to pilot error. However, before the pilot embarks, the plan can simply be to identify the critical aspects of the pilotage where the bridge team will have to be particularly alert. The plan can also involve reminding the whole bridge team that pilots can make mistakes and that it is therefore important for the team to be mentally alert and prepared to speak up if there is any concern over the pilot’s orders. Perhaps a final consideration to a pre-pilotage plan would be whether or not to proceed with the pilotage. If, for example, the weather conditions become marginal or the master is not fully satisfied with the pilot’s plan (or even his competence) he may deem it prudent to hold back and to re-assess the situation.

Many situations, such as those mentioned in the above cases, occur on ships every day and although each situation will be different, time will often permit a plan to be developed to deal with a situation from the moment it becomes real.

Planning for the unexpected – Barriers
It is important to recognise potential barriers to planning for the unexpected and, perhaps more importantly, to carrying out plans. Amongst many that could be mentioned, the following examples are given:

– Language and cultural differences – These can generate reluctance within the bridge team to speak up if there is concern in a particular situation. The pilotage case involving the bulker grounding mentioned above is a good example.
– Shore staff support – Even if only perceived, a suspicion may exist on the vessel that the shore staff will not support a decision taken on the vessel, for example not to proceed with a pilotage.
– Customer satisfaction – The need to avoid upsetting a charterer by taking a longer route.
– The need for speed – To quote a recent UK investigation report on a major casualty, “speed and quick turnarounds appear to have become the focus of the industry at the expense of the safe operation of its vessels.”
– The desire to save money – For a vessel without her engines far off land one can appreciate the temptation to attempt repairs before calling in potentially expensive external assistance.

Planning for the unexpected– Solutions
Perhaps the most important solution is mental preparation. If crew members have their minds preoccupied with other things, or have persuaded themselves that something bad will not happen, then chances are that they will not consider “what if…?” scenarios and will not react properly in a developing situation. Training, exercises and drills are good opportunities to test crew reaction to scenarios that have the potential to develop into an emergency. It is also possible to encourage people to think in terms of “what if …?”. One way to do that is to give positive praise for challenging attitudes and prudent over-reaction. So if a junior officer challenges a senior officer on his choice of course he should be praised, even if the junior officer’s concern turns out to be unfounded. The junior officer should not be chastised. If the master’s decision to take an extra tug is not wholly unreasonable, his action can be supported.

At the moment a situation does arise, which calls for a plan, it will be important to bring together minds to discuss “what if…?” scenarios. In many of the cases mentioned above, the deck officers could have had a quick brainstorming session before they found themselves in a developing situation which required them to react without a plan. In cases involving engine failure, the session would obviously involve the engineers and the value of shore staff involvement should not be underestimated, since they are likely to be less distracted by the situation itself. An agenda for a “what if…?” brainstorming session might include the following:

– situation description
– what are the main dangers/risks to the crew/vessel?
– what could change that would increase/ alter the danger/risk?
– what are the worse case scenarios?
– what is the plan?
– what is the back-up plan?
– what if …?

In a collision situation, a brainstorming session is less likely to be practical, but the officer of the watch should not be afraid to discuss potential problems with the lookout, e.g., “do you think that vessel clearly understands our intentions?”.

The investigation of near misses is worth a mention. These can be vital in terms of detecting whether any barriers exist and may provide an opportunity to do something about them before a near miss becomes an emergency which is out of control.

Asking “what if …?” in a developing situation on board a ship and planning accordingly may make the difference as to whether or not that situation develops into an emergency. At the very least, it may buy the crew and ship vital extra time. Even if your own ship has what is considered to be the best crew, the much debated skills’ shortage and ever-expanding world fleet raises questions about watch-keepers on other vessels, pilots and whether they will behave as expected. As for the weather, it can always do the unexpected and perhaps climate change will make forecasting even less reliable.

Two small words, “what if …?”, are worth keeping in mind.

1 See article “Pilot error survey” in Gard News issue No.186.
2 See article “Pilot on the bridge – Role, authority and responsibility” in Gard News issue No.160.
3 “Rubicon – The point of no return”.


Gard News 193, February/April 2009

Any comments to this article can be e-mailed to the Gard News Editor.

Gard News is published quarterly by Gard AS, Arendal, Norway.