Exxon Valdez Incident

[Kennebec Captain]

Here is a time line of the EV incident, the chart shows the track-line


chart 1.jpg


Mar 22, 1989

2335 Exxon Valdez Arrives Valdez Marine Terminal

Mar 23

0054 Transfer of ballast water started
0415 Transfer of ballast water complete
0505 Transfer of oil began
1030 Hazelwood, Glowacki, and Roberson went ashore
1924 Loading of cargo completed
2020 Pilot Murphy arrived at the ship for the outbound trip
2030 Hazelwood, Glowacki, and Roberson returned to the ship
2040 Hazelwood arrived on the bridge to find the pilot waiting
2112 Last line
2121 Vessel clear of Dock
2130 Hazelwood left the bridge
23__ Hazelwood returns to bridge
2324 Exxon Valdez drops off the pilot
2330 Hazelwood changes course to 200T
2339 Third mate Cousins plots a fix / Hazelwood changes course to 180 T (due south)
2353 Hazelwood leaves the bridge, orders third mate Cousins to change course when abeam Busby Light (2 minutes ahead)
2355 Third mate Cousins plots a fix abeam Busby but does not change course.
2400 (midnight) Lookout reports Bligh Reef on the Stbd bow - Cousins orders Right 10 rudder
Mar 24
0004 Cousins orders right 20 rudder
0007 Cousins orders hard right
0009 Exxon Valdez strikes Bligh Reef at 12 kts.(at 12 kts 1 mile = 5 minutes)

[shipmate 1]

Cousins waiting .75 miles to late to bring the ship back into the outbound lane was the main factor. Also, him not knowing
how to switch between auto and hand steering was not good.

[Kennebec Captain]

At 11:25 p.m. Hazelwood informed the Vessel Traffic Center that the pilot had departed and that he was increasing speed to sea speed. He also reported that "judging, ah, by our radar, we'll probably divert from the TSS [traffic separation scheme] and end up in the inbound lane if there is no conflicting traffic." The traffic center indicated concurrence, stating there was no reported traffic in the inbound lane.

Hazelwood told traffic that he was going to "end up in the inbound lane" but according to the chart the EV left the inbound lane at 2347 and according to the time line Hazelwood didn't leave the bridge until 2353, after the ship had completely crossed the inbound lane.

I don' t know if this info is correct or not but it makes me wonder if Hazelwood had any idea where the EV was in relationship to the lanes. If he intended to stay in the inbound lane the turn back should have been started before 2347.

K.C.

[cappy208]

So if what you have posted is true, Cousins could not follow the order to come right to the original parallel course at the prescribed time (position), and in fact simply did nothing. Too late and too little.

Sounds as if Cousins was extremely lucky to have kept his license! But as I said in the other post, often this is not followed up on by the CG in the industry. Nothing is done until post accident. Even then generally what is done is a knee jerk reaction.

The issue of 'self certified recency' for tank barges less than 10,000GT is another topic near and dear to my heart. Nothing is done except 'post accident.' But by then it is too late. Then again, why is every towing vessel operator not being held to the same standard? How many tows are being run by guys who don't meet the criteria for not hiring a pilot, But get away with it?

My reference to the above topic is the Bouchard Evening Tide, B No 120 incident in Buzzards Bay.

The Mate was hired over the Captains objections (actually 3 or 4 Captains had rejected the individual) The Captain was told, that was his Mate, and if he didn't like it, quit. The Captain sailed, and didn't order a pilot for the portion that was going to be on the Mates watch. The mate admitted he only had a half a round trip in the waters. He was never found at fault with the 'Taking a berth which he was unqualified for.' Which to me sounds a lot like negligence. And the office was NEVER taken to task for hiring an incompetent (unrecommended) Licensed Officer. They paid a fine of around 6 million dollars for killing 3 migratory birds! Never was there a mention of the corporate responsibility over hiring an Idiot, and forcing him aboard a boat.

Once the corporate end is held accountable, there would be no need for all this ISO/ISM, RCP, vettings, oversight. None of it. Corporate needs a wake up call. Just a golden parachute ain't doing it! Neither is blaming the crew. Again.

When the laws are upheld that are on the books, there wouldn't need be a cadre of lawyers salivating over this crap. (Sorry Shell Answer man!)

P.S. I know of many places that if someone didn't come to the new course in 17 minutes there would be an incident.

[Kennebec Captain]

If the turn was made when abeam Busby Island at 20 degree right rudder the EV would have burned up another 0.7 of a mile to get to a course parallel to the original track and would have been two mile from Bligh Reef. However I don't see any reason to have to make the maneuver like that. Better to start easing it back on course after crossing the separation zone and make a gentle - no ship handling skill required, nice easy turn into the inbound lane.

Here is the story from Outdoor where Hazelwood make the turn in a simulator.

K.C.

[cappy208]

how the heck are you digging all this stuff up? most of this was before computer and internet. ( at least before al gore invented it!)

[Kennebec Captain]

how the heck are you digging all this stuff up? most of this was before computer and internet. ( at least before al gore invented it!)

The chart and some of the times are from Visualizing the Decision Space (big pdf file)

The rest of the times and the quote is from Details about the Accident from Alaska Oil Spill Commission which is the go to for info.

K.C.

[RubberRhib888]

K.C.,
I just found your blogspot about 5 minutes ago...good stuff. I have a question regarding the speed of the EV. If there were reports and confirmations of drifting ice in the immediate area, why the heck was the EV doing 12 knots? Isn't rule 6 Safe speed?? "Every vessel shall at all times proceed at a safe speed so that she can take proper and effective action to avoid collision and be stopped within a distance appropriate to the prevailing circumstances and conditions". Your chart plot shows the area with the ice. Was this condition so "normal" that the EV and her crew got complacent? (in your opinion) I understand the error chain, however, it appears to me that there were other circumstances at play. Specifically the conditions of the ice and speed...not to detract from the actual course and lack of following the captains orders. I know it's easy to look back at something over 20 years ago and pick it apart. (Just a curios and aspiring mate)

[RubberRhib888]

correction: curious mate

[Kennebec Captain]

K.C.,
I just found your blogspot about 5 minutes ago...good stuff. I have a question regarding the speed of the EV. If there were reports and confirmations of drifting ice in the immediate area, why the heck was the EV doing 12 knots? Isn't rule 6 Safe speed?? "Every vessel shall at all times proceed at a safe speed so that she can take proper and effective action to avoid collision and be stopped within a distance appropriate to the prevailing circumstances and conditions". Your chart plot shows the area with the ice. Was this condition so "normal" that the EV and her crew got complacent? (in your opinion) I understand the error chain, however, it appears to me that there were other circumstances at play. Specifically the conditions of the ice and speed...not to detract from the actual course and lack of following the captains orders. I know it's easy to look back at something over 20 years ago and pick it apart. (Just a curios and aspiring mate)

I don't know about the appropriate speed in the ice. For sure there was complacency on the part of many parties.

We don't really know what happened on that bridge but what strikes me is the situation that Hazelwood put Cousins. Cousins escorted the pilot to the ladder and came back to the bridge. The captain had the conn, made two course changes with the result that the ship was headed directly for Bligh Reef, put the engine on the load up program which meant the speed was constantly changing and he put the ship on auto-pilot. What else could he have done to make the 3/M job more difficult?

I don't know if there was a plot on the chart on not but it would have been standard practice to lay out track-lines and label the time to turn at Busby along with the course that Hazelwood wanted the 3/m to steer. I suspect none of this was done.

Cousins may have walked into a very difficult situation. It is very possible that he had never handled a tanker before in confined waters. Typically this is beyond what is expected of a third mate. The fact that he used 10 degrees of rudder initially when 20 was needed indicates he was not an experienced ship handler, I've never meet a third mate who was.

We wonder what he was doing for the 5 minutes between when he passed Busby and ordered the turn started. I've seen many third (and second) mates making endless trips from radar to chart with an occasional quick trip to the window trying to confirm the situation. This might be what Cousins was doing. Then the lookout reported Bligh Reef light on the stbd bow things may have clicked and he started his turn.

Another point is why didn't he call the captain? Again we don't know. I called a captain one time and he was drunk. I never called him again.

As far as the blame between the third and the captain - without fully knowing the facts it's my view the it is 100% the fault of the captain.

K.C.

[RubberRhib888]

Understood. Side note: You and a couple of other seasoned veterans on this forum should consider an educational section on gcaptain. I have been reading for a while and just started to post recently. I see a lot of value in the positive, informative, and educational threads that are sometimes started. This is just something I have been pondering for a while. Thanks for the swift reply to my query and I am more informed due to your post. I appreciate it.

[mtskier]

Any documentation regarding the AB on the wheel. Part of what I was told while working in Valdez was that the AB didn't realize that he was on auto pilot and was passing back responses to rudder commands even though they weren't actually occurring...

[CaptRob1]

A couple of things. I was up there after the spill and on the first "Escort" vessels for Zapata Gulf (Heritage and Liberty Service). The Valdez diverted course because there was ice coming out of the Glacier into the traffic lane. There was no traffic inbound, so they were given permission by the VTS to cross into the inbound lane.

What I had heard was that the ship was on hand steering and not on the auto pilot. I guess that part was not passed on from the Chief Mate to Cousins. When Cousins made the order to change to starboard, the ship did not respond. Dont know why, it was not caught at that time by looking at rudder angle indicator. But it wasnt. Then 5-10 more rudder was order and nothing, and then when it was realized what was going on, it was ordered, hard over, but by then, it was too late.

At that time, there was no speed curfew. When we first started following the tankers out, there were no speed curfew. Then I guess it was about a year, and they cut them to 10 kts.

I spoke with Cousins in about '92 or so and he was still sailing at that time. For one of the Unions. He was testing for his Chief Mate or Master's.

[Kennebec Captain]

Any documentation regarding the AB on the wheel. Part of what I was told while working in Valdez was that the AB didn't realize that he was on auto pilot and was passing back responses to rudder commands even though they weren't actually occurring...

In many incidents it seems that things reach a point where if everything goes perfect the incident can still be avoided but errors are made or latent errors surface which become factors in the accident. Often there is a lot of focus on the accident factors which occur after the root cause has set the incident in motion but before the incident in inevitable.

Hazelwood set things in motion when he steered the EV outside the lanes and left the bridge leaving the safety of the ship dependent upon the ability of the third mate to quickly size up the situation and take the right action.

At that point Cousins couldn't cope with any more errors of any kind. What he needed at that point was a way to reduce risk, specifically what he needed was a rested officer that had situational awareness and experience handling a loaded tanker. There was such person available, Hazelwood.

An important consideration in steps taken to reduce risk is the cost of those steps. In this case the cost was Hazelwood spending another 2 minutes in the wheelhouse. That couldn't have been much to ask as he had spent the day ashore.

K.C.