MRM Case, WSL Guide Figaro/Camargue, page 1

Last amended: August 20, 2007

MRM CASE – FIGARO/CAMARGUE

When to use: After A&A
Messages: Hazardous thoughts, C&B, A&A, C&R, lack of STS

1. Did the pilot of the Figaro have any hazardous thoughts? Which ones?

2. Comment on the communications and briefings on board the Figaro, and on the
Camargue. The Camargue was much better. There was probably a language problem
because the pilot did not speak clearly.

3. Who failed to challenge the pilot? Why? The master was not assertive enough and let
the pilot dominate his authority.

4. There was no discussion about the timing and unnecessary speed used by the pilot. No
Short Term Strategies were used.

5. There was no discussion about bank effect.

“Our Response”:
The TDQ in this case reads: In terms of MRM, what caused the collision between the Figaro and
the Camargue?

Let us first deal with the Figaro and focus on the management cornerstone: Communication! We
see the pilot come onboard and immediately take the initiative by ordering full speed ahead. The
master made a vague effort to involve the pilot in some kind of technical briefing, but was more
or less cut short by the pilot’s statement, that he was familiar with this type of vessel. The master
accepted this. We do not see any attempt from either the master or the pilot to initiate a proper
briefing. However, from the actions of the pilot, the master soon became aware of the pilot’s
plan to overtake a preceding vessel. Such a manoeuvre may not be regarded as very advanced
from the pilot’s side, but as a master and responsible for the safety of a big vessel in confined
waters, we would have insisted on being involved in the pilot’s intentions in detail.

The pilot’s attitude was not a friendly one and did not invite to conversation. This fact may have
been a reason for the master’s failure to forward to him information about the late
commencement of unloading (or loading) the cargo. Had this come to his attention, he may not
have been so focused on overtaking the Camargue.

The first sign of concern on the bridge of the Figaro is, when the master realised, that overtaking
the Camargue tended to be a slow affair and on his own initiative increased the speed.

The closer the Figaro came to the Camargue, the more concerned became its master, while the
pilot’s state of mind seems to remain somewhere around normal. His saying “he had done this
manoeuvre many times” seems rather indicate his state of mind even to be on the minus side of
“normal”.

The communication on the bridge of the Figaro when the risk of a collision became evident is
not what we are looking for in times of danger. The helmsman did not inform the pilot, that the
rudder was hard to starboard. The pilot was unaware that the Figaro was swinging left, because

Copyright © 1993-2007 The Swedish Club

MRM Case, WSL Guide Figaro/Camargue, page 2
Last amended: August 20, 2007

the helmsman was slow to tell him. The helmsman “thought” he heard the pilot say “keep...hard
starboard”. Wanted: Closed loop communication.

Just prior to the collision the master had a burst of adrenaline that made him start acting. But too
late! His earlier inactivity had already led him and his vessel into a position, where nothing could
be done to avoid hitting the Camargue. The behaviour of the pilot in this highly critical situation
is somewhat hard to explain. He seems to drop into a state of passivity - maybe bordering to
apathy. Like the air going out of a balloon.

While we can see much amiss on the bridge of the Figaro, when it comes to management, we
think the behaviour and actions on the Camargue to be of a quality one would expect to find
among professionals.

ν ν ν

Copyright © 1993-2007 The Swedish Club