For those of you who hold an interest in BRM, this ATSB report is a fascinating indication of human error on many levels. It involves the bridge team, engineroom duty engineers and towage crews.
The breakdown in checking of RPM tachometers was nothing short of stellar. It was missed by four bridge team members and three engineers in the control room. The first indication that the main engine was still running ahead was offered by the Master on the aft tug. Many lessons were learned from this report and it is a great reference tool.
Also attached is a video of the incident.
BUT……….as we all know, history repeats itself.
11 years later a very similar incident occurred with the Pilot exempt cement carrier “Goliath”. Once again……human error and *once again, the indicators were not checked at a critical juncture.
*The preliminary report has just been released and I have attached a video of the incident.
It’s interesting that the report mentions that the ship is required to send the ship’s drafts to the port two days before arrival but the ship doesn’t get a passage plan from the port till the pilot boards.
Here’s the plan the ship gets upon pilot boarding.
No courses or speeds.
In this case it’s doubtful it’d would made a difference either way but the according to the report the port is going change policy to show speed zones and courses on the plan.
It’s not surprising that the third mate didn’t notice the error but you’d think the captain would be watching the tach closely in that situation.
Our bridge engine telegraph console had both a “wrong way” light and a loud buzzer.
Here is the kicker from the report…….
“Should this occur, the alarm and monitoring system is designed to detect the discrepancy between the telegraph order and the actual direction of rotation and a flashing visual ‘wrong way’ alarm on the ERC and bridge telegraph consoles is activated (Figures 2 a & b). However, when the main engine is operated from the engine room control room, the Norcontrol AutoChief III bridge control system’s ‘wrong way’ running interlock and audible alarm protections are by-passed.”
So the WWA was automatically by-passed. One would assume that this would drive all members towards double checking indicators.
This incident beggars belief.
Sounds like a checklist item for pre-arrival/departure gear tests.