Navigational Leading Events Analysis – H1 2021

Introduction

This analysis is based upon data from our near miss reports, unsafe act and condition
reports, input from Tanker SIRE observations, Internal Audits, SeaTec Reports, VDR
remote audits and Navigational Audits.

The Hi-Lo data has predicted Navigation UDEs for our fleet, the following being the top
two UDEs:

➡ Collision with vessel less than fifty meters

➡ Allision and grounding.

The leading events are categorised according to High Impact, Low Frequency (Hi-Lo)
categories which, if not addressed, may tun into Undesired Events (Incidents)

NUMBERS
INCORRECT ANCHORING PROCESS
UKC NON COMPLIANCE
BRIDGE CONTROL SYSTEM FAILURE
LOSS OF ANCHOR CONTROL
ANCHOR DRAGGING/LOSS OF RESTRAINT
LOSS OF THRUSTERS
LOSS OF STEERING
NON –COMPLIANCE WITH COLREGS
LOSS OF PROPULSION
THIRD PARTY ACTION/IN ACTION
NAVIGATION EQUIPMENT FAILURE
FAILURE OF BRIDGE TEAM MANAGEMENT
INADEQUATE CHART MANAGEMENT

0 10 20 30 40 50 60 70 80

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 Failure of Bridge Team Management (21% of Leading Event)

Radar & ECDIS

Issues

➡ Wrong alarm and input setting

➡ Wrong operational setting
➡ Poor position monitoring
➡ Incorrect setting on RADAR/ARPA for collision avoidance.

Examples:
▪ Radar Gain, Sea and rain clutter not adjusted properly
▪ ECDIS unit ENC display mode switch on to BASE layer
▪ Inappropriate speed mode input in ECDIS and RADAR
▪ Safety Depths settings in the passage plan for ECDIS were found to be incorrect
▪ RADAR alarms on CPA and TCPA found set to zero and muted
▪ ECDIS units power supply is from emergency switchboard. Power back up
(UPS) for ECDIS are not provided
▪ The concept of ECDIS safety settings such as safety depth/contour and shallow
contour was incorrectly implemented. For instance, with vessel's draft 6.5 m
safety depth was 20m, safety contour 10m and shallow contour 10m.

Pilotage Operation
Issues

➡ Master/ Pilot information exchange not carried out/ or incomplete

➡ Poor communication between bridge team/Pilot/Tug
➡ Incorrect/Conflicting orders communicated by pilot
➡ Use of regional language by pilot

Examples:
▪ The Master Pilot Exchange of Essential Information Form NAV 05 was not
completed
▪ The master pilot exchange of information checklist was not signed during
departure Singapore
▪ Regional Language was used by the bridge team and pilot during pilotage and
berthing
▪ Pilot gives the wrong command on vessels heading while navigating in the
Houston Ship's channel

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 ▪ While vessel in outbound pilotage from Chevron Richmond Long wharf, Pilot
ordered starboard 20 rudder while signalling his left hand to port
▪ Pilot tends to change the settings of the Auto-Pilot system without noticing
despite of the instruction given by the master during 'Master / Pilot Info.
Exchange'
▪ While transiting Suez Canal, the pilot was on board and navigating the vessel.
On approaching alteration point, it was noticed that pilot while sitting on the pilot
chair had dosed off and was not giving the required helm order.
▪ Collision with stationary objects during pilotage. Pilot unfamiliar with the current
condition in the port channel.

Lack of Situational awareness /distraction

Issues:

➡ Pilot talking on cell phone while vessel was executing alteration.

➡ OOW using vessels or personal devices (laptop, smartphone, PC, music
system)
➡ Lookouts engaged in personal activities.

Examples:
▪ Vessel was fully laden and drawing a deep draft of 16.3 meters. Vessel was
executing a wide alteration to port to enter the exit channel and Pilot was
ordering the Course to Steer. Pilot was also on his personal cell phone
communicating in local language and was distracted as he was also preparing to
disembark. While conveying the course to steer, he ordered an incorrect course
which could have caused vessel to steer out to the exit channel and possibly run
aground.
▪ OOW was found by the Master sitting in front of bridge PC while two ships
(overtaking and overtaken) are in the close vicinity
▪ OOW was watching some video on his private smartphone during navigational
watch
▪ While in navigation, out of TSS Ushant, high density traffic area, night-time, the
officer on the watch was playing with personal smartphone, in the chartroom
▪ Music being played on bridge during pilotage
▪ The bridge team failed to notice the wrong helm given by the helmsman. This
was corrected by the pilot

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 Lack of Training and Non-Compliance

Issues:

➡ Junior OOW lack of knowledge of bridge equipment and limitations.

➡ Handing over taking over watch inadequate
➡ Helmsman frequently applying incorrect helm
➡ Officer not familiar with company procedures.
➡ Officer not familiar with UKC policy and procedures.
➡ Compass Error not obtained in every watch

Examples:
▪ Officers were not familiar with the Company policy for crossing the safety
contour
▪ Vessel did not report to Adabiya VTS before entering Gulf of Suez TSS
▪ Helmsman unable to steady at final heading and vessel swinged ten degrees
more
▪ A deck watch officer was asked to demonstrate the process to switch the GPS
input to the ECDIS from GPS unit #1 to GPS unit #2. He was not able to
perform the task.
▪ Deck officers unable to demonstrate manual position plotting on ECDIS
▪ Radar Stabilization was not set correctly
▪ Gyro compass error was not obtained every watch as required by Container
VMS/FOP/3.13.5.
▪ The procedure on use of BNWAS was not followed as system being kept off
while underway at sea
▪ UKC not calculated with due diligence for vessel departure from Singapore and
while enroute Dar Es Salaam
▪ Vessels UKC calculations for previous voyages found not correct. NAV 03 used
was not valid

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 Loss of Steering / Propulsion / Thrusters

Issues

➡ Main Engine either fail to star or suddenly stop or slowdown due to varied
reasons.
➡ Rudder stuck and blocked
➡ Thruster malfunctioned

Examples:
▪ During inbound St. Sampson pilotage rudder blocked in position Hard to Port
▪ Vessel was departing jetty at Pointe a Pierre with pilot onboard. While
maneuvering and last line casted off, bow thruster is run full to port then
suddenly stopped.
▪ During maneuverings 16.02.2021 ME slowdown alarm was received due to
Electric Control System failure
▪ The bow thruster was not in use as the pitch indication on bridge was showing
erratic

Inadequate Chart management

Issues

➡ Prominent navigation and radar marks not done

➡ Method & frequency of position fixing not marked
➡ Chart and publication not updated
➡ Nav area warning missing /ignored by OOW

Examples:
▪ Passage Plan for last voyage indicated position-fixing frequency of 60min while
on coastal passage. Fleet operating instructions indicate 30 minutes during
coastal passage.
▪ ECDIS chart has not been updated with Murmansk Coastal warnings
▪ Sailing direction NP14 Australia Pilot Volume 2 not available onboard
▪ No passage plan available from Constanta anchorage area to Constanta berth
and no manual plotting position at the Constanta approach chart
▪ 9 no. s ECDIS ENC for present voyage and 10 no. s ECDIS ENC for next
voyage is displayed as NOT UPDATED on ECDIS

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 ▪ Passage plan form and the ECDIS safety contour was at 11m. Calculated safety
contour value in NAV03 was 12m coastal and 18m open sea.

Nav Equipment & Bridge Control System Failure

Issues:

➡ ECDIS failures (Alarm off, Overheated, unexpected shutdown)

➡ RADAR failures (Intermittent screen power off, Antenna issues, Magnetron
failure)
➡ Gyro (Incorrect heading, repeaters not synchronized)
➡ Air bubble sighted in Magnetic compass
➡ GPS lost signal/unstable signal.

Examples:
▪ Intermittent GPS failure causing ECDIS failure
▪ S-band radar out of order. Antenna is not rotating. Magnetron failure is observed
▪ There is a difference in heading between Master Gyro and repeater in steering
gear room
▪ The Gyro no.2 was showing incorrect heading, with a difference of about 32 deg.
from the Gyro no.1
▪ GPS # 2 lost signal due to worn cable
▪ An excessive error of magnetic compass and liquid leakage from compass bowl
(drained approx. 20%) were noted. The magnetic compass heading was 063
degrees when gyro heading indicated 240 degrees.
▪ X Band radar screen power was observed intermittent

Non-Compliance with COLREGS

Issues:
➡ Inefficient lookout
➡ AIS used for collision avoidance
➡ Navigation light unlit/defective
➡ Other vessels not following COLREGS and creating close quarter situations
➡ Own and Other vessels dragging anchor

Examples:
▪ AIS information on Radar / ARPA particularly CPA & TCPA relied upon for
collision avoidance

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 ▪ Vessel nav. stbd side light is unlit
▪ It is observed that while vessel was navigating in channel both radars were on
Ground speed (GPS) not on log speed (STW) as required and used for collision
avoidance purposes.
▪ Excessive internal illumination on the bridge while vessel at anchor. Which leads
to poor lookout and improper monitoring of the vessel surrounding area.
▪ Look out was not present on bridge. Same not heard on VDR playback and not
recorded in deck logbook
▪ During anchor stay at Rotterdam OPL Anchorage No.5, at morning watch it was
observed that vessel was dragging anchor

Remote Navigation Assessment Through VDR Data (Q1&Q2 2021)

➡ Total Audits: 62
➡ Non-Conformity: 122
➡ Observations: 254
➡ Total findings: 376

Categorization

40
35
30
25
20
15
10
5
0

Obs

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