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First a note… I am publishing this short clip ahead of my next article because of its importance!

While preparing our upcoming “questions for investigators” article on the Cosco Busan incident we were asked by more than one party a question along this line; with communications failure being a leading cause of incidents and the crew of the Cosco Busan being Chinese of limited english skills (they required translators during the investigation) why do incidents of this type not happen more often?

The answer is Bridge Team Management.

Ok… so what is BRM?

Revisiting a previous post I state:

• Bridge Team (or resource) Management (called BRM in the industry) is a process to use all of your available resources during critical operations. It came from the airline industry which found an alarming number of accidents happened despite prior warning from the equipment or crew…. mostly by captains with military backgrounds and a “I can do this” attitude who did not fully use critical information from either the equipment or junior personnel.Boiled down it’s a class all officers must take in both teamwork and processing the large amounts of data (lookout reports, radar, radio comms, gps charting, weather information….) that pours into the bridge.
• Here’s a more official answer:The Bridge Team Management course introduces the concept of a navigation team to ship masters and watch officers and frames their decision making process toward establishing watch conditions during the course of the voyage. Bridge Team Management techniques will emphasize decision making based upon conditions related to workload and potential threat to the vessel. The intent of the program is to define the individual task and responsibilities of the various team members while developing a situational awareness to prevent individual errors.

In stating the importance of this post I am looking at the media reaction to the incident. In reporting disasters the public is often not satisfied until a single individual is blamed…. quickly. This was the case in the Exxon Valdez oil spill, Tampa Skyway Bridge Disaster and even in the early reports on the Empress of the North grounding where fault was placed on the Jr. Officer on watch who was only weeks out of the Maritime Academy. In the Empress of the North incident gCaptain broke from traditional media and laid the blame on management techniques rather than the “green” officer and we are happy to report he was recently clear of all charges (as was Capt. Hazelwood of the Exxon Valdez).

It is clear to us the Cosco Busan allided with the Bay Bridge because of a breakdown in Bridge Team Management. For example while VTS contacted the ship questing its course did the mate on watch, captain, helmsman or assist tug captain also voice concern? Was the equipment operational and set up properly? As the primary fault for the Exxon Valdez incident was not with Captain Hazelwood (he was cleared of charges and his license was reinstated) John Cota, Pilot aboard the Cosco Busan is not solely at fault for this incident.

The team failed the Cosco Busan not the ship’s Chinese Captain or American Pilot alone. Lets just hope the court of public opinion does not convict either person before the long and thorough investigation is completed. Otherwise they might stand the fate of Captain Hazelwood, cleared of charges and fully licensed to pilot a ship but unable to find a company willing to hire him.

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Asking yourself how a ship 131 wide could have such trouble in a channel 737 metres wide? Read a more unbelievable story HERE then watch the amazing slideshow HERE.

UPDATE: Bob Couttie of the Maritime Accident Casebook has a very interesting article along similar lines. You can find it HERE.

UPDATE 2:
Criminal probe opened in Bay oil spill

The entire crew of the cargo ship that sideswiped a bridge, causing San Francisco Bay’s worst oil spill in nearly two decades, has been detained as part of a criminal investigation, a Coast Guard official said Sunday.

Capt. William Uberti said he notified the U.S. attorney’s office on Saturday about issues involving management and communication among members of the bridge crew: the helmsman, the watch officer, the ship’s master and the pilot.

On a recent story I confused the Norwegian Dawn with the Norwegian Dream. The error itself is small but the implications are large and the reason for the error gives me the opportunity to shed light on the cause of so many maritime incidents. A short explanation might give you a look into the mind of a ship’s captain, so here it is;

Some articles are the result of hours spent researching, writing and editing while other posts are simply excerpts of stories found elsewhere on the web. My Norwegian Dream post was part of a general interest series we run called “Incident Photo of the Week“. These posts are designed to be short, interesting and easy to write and only require one line of explanation but, sufficient to say, I did not put much time into the “easy” job of posting the article.

Aboard ship 90% of the navigational jobs are easy. Some jobs, like departing Valdez Alaska, seem difficult to an outsider but are simple tasks for an experienced mate. This is the very reason Capt. Hazelwood of the Exxon Valdez left the 3rd mate in charge of the watch. These simple tasks, however, can result in tragedy caused by an even simpler mistake.

Moving large ships is not the only profession requiring complicated mathematical calculations, little room for error and disastrous consequences but marine navigation differs from professions like structural engineering because we have no brakes. The time is ticking on a large ship and errors are often not seen until after the danger has passed. During the incident you can not stop the job and spend hours reassessing the hazards, Newton’s law of motion doesn’t allow it. This is why my error in reporting the story is significant and had it been made aboard ship would be cause for alarm.

So how does a captain prevent the simplest mistakes from becoming catastrophic incidents?

The first is training. While a brilliant structural engineer could be given the top spot at a young age this is not the case with ship captains. At the minimum regulations require 10 years of sea time in addition to hundreds of hours of course work and multiple levels of testing prior to being allowed by the Coast Guard to sit for the Master Unlimited exam. This method of advancement prevents a shining star from rising quickly but not for his lack of knowledge, rather from his lack of experience. This is required to give an officer the time not only to learn the theory and application of job specific tasks or even to give the time required to actually witness the full gamut of possible situations, although both are important. The primary reason is to a mate the time needed to feel the ship and understand/compensate for his limitations. The ability to master this is the mark of good captain and one reason companies prefer promoting older chief mates and rarely hire someone based solely on his qualifications (note: this is changing).

The best captains can identify instability by the feeling the roll of a ship, correlate the simplest annoyance with a larger problem (e.g. a sticky door caused by hogging) or recognize the tone of an officers voice that masks concern. They not only can identify but also have developed processes for solving problems. Last they know their own shortcomings and have built a system to identify and manage them.

In my case I have the occasional tenancy to correlate similar information so in this case my mind failed to separate the Norwegian Dream from the Norwegian Dawn. Aboard ship I would combat the problem by writing down each name on opposing sides of a yellow note pad and keeping relevant notes separated by space.

Second I am careful to listen for the voice in the back of my head that whispers “Something Is Wrong”. I have found this voice to be present 90% of the time prior to identifying a problem. It is important to note that incidents are not caused by single failures they are always the result of what our industry refers to as an error chain. The clearest example of this chain would be a catastrophic cylinder failure in the main engine. To most this type of failure would be classified as bad luck but mariners are trained to realize this is not the case. I use the following example because I recently read an incident report on a cylinder failure that was ten pages long and took 6 months to complete. The findings were nothing spectacular, rather they described many small problems dating back decades. The findings included an overworked engineering officer in charge of lubrication (days before the incident), the supplier substituting lubricants not ideal for that particular lube oil pump (the previous year) and even the designers failure to relate this seemingly small problem to the manufacturer 15 years prior to the failure. In this case all seemed well but I would bet heavily on the presence of a voice in back of the Chief Engineer’s mind calling out “I can’t identify it but we have a problem” his daily routine simply drowned it out. If he had identified just one of the links (minor causes identified in the report) in the error chain and removed it the incident would not have occurred.

Last I always step back and take a “time out”. This simple and effective technique taught in Major Emergency Management, an optional class in managing nightmare situations, closely resembles something we learn at a young age; step back, take a deep breath and ask yourself “what doesn’t make sense here?”

So putting it all together I could have avoided the mistake by first writing the key points down on a note pad and separating similarities (the ship names). Then I could have actively listened for the voice whispering (or in this case shouting) “something is wrong” and finally, if I had failed to identify the difference in the first step, I should have called a personal time out, stepped back and asked myself “does this make sense.” If I had done this I would have quickly realized the obvious fact that containers do not belong on a cruise ship.

Why didn’t I? …well this is just a blog, right?

Many thanks to our loyal readers for finding the error, especially Perry. Despite my initial annoyance from his repeated corrections a good captain must always smile when a concern is related (even when woken at 0400) and hopes all of his makes are just as diligent and persistent. It’s the “easy” posts, after all, that often results in longest incident reports.

Stay Safe,

John

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John Konrad is a USCG licensed Master Mariner of Unlimited Tonnage and the editor in chief of gCaptain.com. Since graduating from SUNY Maritime College he has sailed 4 of the world’s oceans and reports from his ship via satellite.

Interested in writing for gCaptain? Contact us today.

CLICK FOR INTERACTIVE VISUALIZATION

With the recent LNG News I decided to get to work on some maritime visualizations. Above is a bubble graph I created representing the number of ships registered to each flag state.

CLICK FOR INTERACTIVE VISUALIZATION

This graph is even more interesting, it shows the number of ships registered to each country by foreign owners. Notice the Flags of Convenience? Surprising that the U.S. has 51 flagged ships registered by foreigners.

Data is from the May 15th 2007 version of the CIA World Factbook.
Total number of ships registered worldwide: 33,222
Total number of foreign owned ships: 16,717.
More graphs of this data:

Merchant Marine - Rank Order (top chart): [Continue Reading →]

In a post unusually harsh for gCaptain standards I asked some tough questions about actions taken by the captain of the doomed ship, Pasha Bulker. Here’s a recap;

…did the crew used their satellite comms to discuss the weather patterns with meteorologists or did they simply ignore the port authority’s warnings? Did the captain use his AIS to identify the surrounding ships and call fellow captains via GMDSS to discuss the situation? Did they have access to and use real-time weather data or wait for a 2-dimensional weather fax?

(read the full article HERE)

Today in a leaked version of the incident report the answer is clearly no.

In a candid interview with investigators the vessel’s captain disclosed his actions in the critical moments between weighing anchor and the ship’s grounding. Take a deep breath as you may find this hard to believe. He was eating breakfast! In the galley!!

Here’s a rundown of events as report by The Sydney Morning Herald (full article located HERE)

The trail of mistakes and incompetence began on the evening of June 7 when warnings about an approaching storm were issued to 56 ships anchored off Newcastle. The Pasha Bulker, waiting to load 58,000 tonnes of coal, was one of 10 ships whose captains chose to stay at anchor about 200 metres off Stockton Beach to assess the situation overnight.

At 5.30 the next morning authorities tried again, but the Pasha Bulker stayed at anchor. It was not until 7am, in a sea whipped up by 100kmh winds, that the captain realised he had to move, and move quickly.

46 ships decide to leave port to avoid dragging anchor in an unprotected harbor and the Pasha Bulker stays, while this action is questionable the decision is not necessarily breaking the rule of prudent seamanship. The next morning Port Authorities “try again” to evict the remaining ships. I do not have details on the warning but it’s normal procedure to give the availability of tug boats that could help a ship in danger. Either way rescue tugs never showed and were apparently not requested by the captain.

At this point the captain became a danger to the vessel and crew. A master’s disagreement with port authority suggestions is understandable and the choice to ignore the warnings are his prerogative but one necessary step was not taken; vigilance. This is the time for a captain to ask himself the questions mentioned above, this is the moment to question your own decision, this is your chance to solidify a bridge team management plan and put the crew on high alert.

The story continues;

As the Sea Confidence, a nearby vessel facing the same predicament began moving out to sea with its anchors still dragging, the Pasha Bulker stayed and attempted to weigh anchor before moving. Mariners say it is standard practice for a boat (sic) to be moved forward slowly to help raise the heavy chain from the seabed while it is being hauled in. It meant the ship would have already moved through the surf in the 10 minutes it would have taken to get the anchor aboard.

In an emergency, such as the one brewing by the 30-year storm, the anchors should be cut and left behind.

Instead, the captain ordered the engines to remain idle while the chain, up to 200 metres long with links each weighing 100 kilograms, was winched aboard. As a consequence, the ship was still in the danger zone an hour later when the anchor was finally shipped.

Here I take exception to the article. While the Chief Mate might have been able to release the anchor brake and allow the chain to fully pay out (the more appropriate action), there is no quick and simple way to cut an anchor chain the size of the Pasha Bulker’s. The decision made aboard Sea Confidence would have been more appropriate to the situation. While some shiphadling ability is lost if the anchor is left down (due to a movement of the vessel’s pivot point forward) the Pasha Bulker has plenty of reserve power and steerage to overcome any serious problem.

It was now just after 8am. With the winds and seas continuing to rise and the engine only just beginning to move the ship, the captain called the chief engineer and invited him to breakfast. Both were Korean in a 22-man crew otherwise made up of Filipinos. They met in the dining room while others were left in charge of moving the vessel through the dangerous conditions.

The Pasha Bulker, now in the hands of less experienced crew, was shunted north along the coast toward Port Stephens, unable to make much headway against the waves. It had traveled about three kilometres before the captain reappeared on the bridge and took command of his ship, which was now out of control.

Was the captain called by the mate on watch when his inability to make positive headway was identified? If the mate on watch was exceptional and the answer to the question is no… the captain might not have been reckless in making this bad decision.

At 8.30am the ship had been looped in almost a full circle by the power of 18-metre waves and was now headed toward Nobbys Beach on the outside of the southern entrance to the port.

The captain, in a panic as he told investigators in the offices of a Newcastle law firm, made one last desperate attempt to save his ship, but again made an error. Instead of swinging it hard to starboard, he ordered it go full astern, literally backing up into the pounding waves that were breaking over its decks. The stern was lifted above the waves, its rudder useless and the propeller spinning madly in the air. The 225-metre vessel then virtually surfed to the beach and hit a rock shelf called Big Ben Reef.

Ships are designed for forward motion. For example, the rudder is placed aft of the ship’s screws in order to benefit from the propeller wash pushing against it. When a ship backs down, however, the propeller wash is pushing against nothing and the rudder must rely on the vessel’s motion through the water to grab hold of water and turn the ship. When the ship transitions from froward to “reverse” motion there is a period of time the rudder is totally ineffective. This is why ships need tugboats when departing a dock… until they reach the minimum speed needed for the rudders to be effective (know as bare steerage) the tug must hold the bow on course.

More importantly an unladen ship with forward momentum and an engine working on an order of full ahead can turn quickly. It is important to note this rate of rotation is a critical factor. If a ship turns slowly (as happens during a reverse maneuver) the ship will have difficulty turning through the wind and can get stuck at a heading beam to (perpendicular from) the wind.

The collision broke the back of the ship - hogging, as it is called. It bent the ship into an inverted U-shape that could be seen by onlookers from the beach as ripples in the hull. The captain panicked again and ordered the ship to be abandoned even though there was no chance of it sinking, having already run aground, and needed at least a skeleton crew to minimize damage and monitor the hull to avoid an environmental disaster. They were taken off by helicopter.

Panic is enemy number one in an emergency situation. While some have more difficulty than others avoiding it a captain should never panic. This is a primary reason it takes 10 years of sailing experience and school to obtain a master’s license. I these 10 years you will be exposed to situations at sea that test your panic trigger, if you are unacceptable to panic or indecision at the time if crisis you should not take command of a ship. Many mariners face difficulty getting promoted to second mate for this very reason as this officer position is the highest pay grade obtainable without the need for making life threatening decisions in the face of danger. I have met few captains to which the Peter Principal applies.

For these reasons I find the report nearly unbelievable.

John Konrad is a USCG licensed Master Mariner of Unlimited Tonnage currently working as Chief Mate aboard a 835′ship in the Gulf of Mexico. Since graduating from SUNY Maritime College he has sailed 4 of the world’s oceans and reports from his ship via satellite.

What is the single most import piece of electronics aboard your ship? For me it’s the EPIRB. If all else fails I will need help fast and the EPIRB is the most reliable and accurate way to get your position to the RCC.

We were first notified of this story by Capt. Richard Rodriguez in the Maritime News Discoverer article titled: “Ship’s automatic beacon didn’t send distress call” and when I read this I immediately notified fellow blogger Rob Stormer. Those of you who follow this blog regularly will remember our previous collaborations on the S/V Sean Seamour’s close call after an EPIRB failure and the captain’s Lessons Learned from the experience.

Rob and the editors of gCaptain are all concerned about an emerging pattern so we have collaborated again to bring you the story of the EPIRB failure and resultant fatalities aboard the fishing vessel “Papa George” last week. Here is the resulting article, a must read for all interested in Safety at Sea: [Continue Reading →]

Need background information for your newspaper, blog, research paper…?

Need help with your job search, career plans, maritime training, coast guard licensing….?

We are trying a new feature at gCaptain; Ask a Maritime Expert. The response to gCaptain has been extraordinary, well beyond my expectations. So far we have built a subscriber list filled with talented maritime professionals.

Recent members include:

• Harbor Pilot
• Chief Engineer
• Marine Biologist
• Workboat Captain
• Shipping Company Owner
• USN Command Master Chief
• Dynamic Positioning Operator
• USCG Civilian Licensing Official
• Master Mariners from numerous vessel types

This is the short list! So if you have a question about Ships or the Maritime Industry post the question to our forum. If you are not happy with the response or have a private question email us (tips at gCaptain.com) and we’ll forward your request to a U.S. Coast Guard licensed Master Mariner. If you’re still not satisfied your welcome to call us hacks on or forum.

Things to remember: [Continue Reading →]

Here is a random selection of the best (and worst) photos of the coal ship “Pasha Bulker” grounded on Nobby’s Beach courtesy of Flickr.
Created with Paul’s flickrSLiDR.

Also Try: FULL SCREEN VERSION

For those unfamiliar with the infamous ship that ran aground on a popular beach in Newcastle, Australia read our past Pasha Bulker stories HERE .

If you liked this then see our similar “Best Ship Photos Slideshow” or our “Most Outrageous Ship Photos” post. The second link is not a slideshow but has some fascinating pictures none-the-less.

*Note, these are updated live from Flickr, therefore we can’t prevent wrongly tagged photos. If your browser doesn’t support the show try this.

Go Back to gCaptain’s Homepage, Blog, Forum or News Discoverer.

….and for our favorite Pasha Bulker photo:

Pasha Bulker

In an interesting turn of events the salvage team working to remove the Coal Ship that ran aground on a popular Australian beach believe Pasha Bulker is damaged worse than predicted. The Herald Sun tells us:

A salvage expert and marine engineer said the cost of refloating the ship and fixing its damaged hull was so close to the vessel’s $41million replacement price it was financially unviable.

If the Pasha is labeled a “total constructive loss”, the ship could be dismantled on site - a task that would take six months, plus time for planning and approval.

If this plan to scrap the vessel happens a new team of experts will arrive to build a pier out to the ship and pump out all remaining fuel oil. Then “big thermal lances and other heavy hi-tech cutting equipment to cut it to pieces, crane it away on trucks and dispose of it.” This process will need to get various environmental and safety approvals before the shipwrecking teams can begin.

Update:

Our readers have been providing quality “Pasha Bulker” updates on this post. The latest (24 July 2007) post from our number one local reporter Ian states:

Local radio this morning, interviewed ‘one of Australia’s leading salvage experts’, Brett Divine who believes that the vessel has sustained serious damage below water and may not hold up to the stresses involved in hauling her off. It appears that his company is one of several already discussing plans to dismantle the vessel should the refloating effort fail.

Read our past “Pasha Bulker” posts.
View our Pasha Bulker Slide-Show.