The whole idea that a third mate “should” be able to handle a loaded supertanker in restricted waters seems absurd to me. It’s not done because it’s a bad bet. The ship was three minutes from the turn when the captain went below.
As far as the radar picture, the vessel was outside the lanes, off course and the area was clogged with ice. The radar picture would not have been what the mate was used to seeing.
Lots of shoulds in this case; 3m should have been plotting fixes, 3m and bridge team should have recognized Bligh Reef buoy on the “wrong” side, etc., etc. but the overriding should is the Master should not have left the bridge under those circumstances. Tanker life might be a bit different than it is now.
According to the report the third mate did take a fix when abeam Busby Island. After that according to the third mate he was using radar ranges to monitor the turn.
The captain put Bligh Reef buoy on the stbd side when he made the course change to 180 to go around the ice so the lookout’s report was not new information. The third mate told the NTSB he had identified the buoy on radar. He was fully cognizant that the buoy was on the “wrong side”. The more salient issue was third mate didn’t recognize that the tanker’s rate of turn was not sufficient to clear the reef till too late.
If what the third mate told the NTSB was correct he really didn’t do that badly. Better than I would have expected from a third mate especially considering fatigue.
His biggest error was not watching the helsman closer, the other error was not keeping an eye on the heading change. He seemed to be watching the radar exclusivity. That’s a very common error for third mates.
No mention of the helmsman repeating the heading change either; another “should have” been SOP given the circumstances and close quarters. Perhaps another bit of mandated procedure not followed.
That’s a good point. Another point is that the helmsman was 12x4 and the 3rd mate was 8x12. Maybe never had a bad helmsman before so not expected.
One thing about poor helmsmen is they do not like high rate of turn because it makes it much more difficult to steady up. If you give a helmsman a rudder order, say 10 degrees, as soon as you give them a course to steady up on an incompetent helmsman will immediately take off rudder or even opposite rudder to reduce the ROT to make it easier to steady up. They like to creep up on the new course nice and slow otherwise they can’t steady up.
It looks like that’s what happened in this case but without the third mate giving a heading.
Dock to grounding
The ship was under the direction of pilot Murphy and accompanied by a single tug for the passage through Valdez Narrows, the constricted harbor entrance about 7 miles from the berth. According to Murphy, Hazelwood left the bridge at 9:35 p.m. and did not return until about 11:10 p.m., even though Exxon company policy requires two ship’s officers on the bridge during transit of Valdez Narrows.
The passage through Valdez Narrows proceeded uneventfully. At 10:49 p.m. the ship reported to the Valdez Vessel Traffic Center that it had passed out of the narrows and was increasing speed. At 11:05 p.m. Murphy asked that Hazelwood be called to the bridge in anticipation of his disembarking from the ship, and at 11: 10 p.m. Hazelwood returned. Murphy disembarked at 11:24 p.m., with assistance from Third Mate Cousins. While Cousins was helping Murphy and then helping stow the pilot ladder, Hazelwood was the only officer on the bridge and there was no lookout even though one was required, according to an NTSB report.
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.
The traffic separation scheme is designed to do just that - separate incoming and outgoing tankers in Prince William Sound and keep them in clear, deep waters during their transit. It consists of inbound and outbound lanes, with a half-mile-wide separation zone between them. Small icebergs from nearby Columbia Glacier occasionally enter the traffic lanes. Captains had the choice of slowing down to push through them safely or deviating from their lanes if traffic permitted. Hazelwood’s report, and the Valdez traffic center’s concurrence, meant the ship would change course to leave the western, outbound lane, cross the separation zone and, if necessary, enter the eastern, inbound lane to avoid floating ice. At no time did the Exxon Valdez report or seek permission to depart farther east from the inbound traffic lane; but that is exactly what it did.
At 11:30 p.m. Hazelwood informed the Valdez traffic center that he was turning the ship toward the east on a heading of 200 degrees and reducing speed to “wind my way through the ice” (engine logs, however, show the vessel’s speed continued to increase). At 11: 39 Cousins plotted a fix that showed the ship in the middle of the traffic separation scheme. Hazelwood ordered a further course change to a heading of 180 degrees (due south) and, according to the helmsman, directed that the ship be placed on autopilot. The second course change was not reported to the Valdez traffic center. For a total of 19 or 20 minutes the ship sailed south - through the inbound traffic lane, then across its easterly boundary and on toward its peril at Bligh Reef. Traveling at approximately 12 knots, the Exxon Valdez crossed the traffic lanes’ easterly boundary at 11:47 p.m.
At 11:52 p.m. the command was given to place the ship’s engine on “load program up”-a computer program that, over a span of 43 minutes, would increase engine speed from 55 RPM to sea speed full ahead at 78.7 RPM. After conferring with Cousins about where and how to return the ship to its designated traffic lane, Hazelwood left the bridge. The time, according to NTSB testimony, was approximately 11:53 p.m.
…cut out a section about fatigue
Accounts and interpretations differ as to events on the bridge from the time Hazelwood left his post to the moment the Exxon Valdez struck Bligh Reef. NTSB testimony by crew members and interpretations of evidence by the State of Alaska conflict in key areas, leaving the precise timing of events still a mystery. But the rough outlines are discernible:
Some time during the critical period before the grounding during the first few minutes of Good Friday, March 24, Cousins plotted a fix indicating it was time to turn the vessel back toward the traffic lanes. About the same time, lookout Maureen Jones reported that Bligh Reef light appeared broad off the starboard bow - i.e., off the bow at an angle of about 45 degrees. The light should have been seen off the port side (the left side of a ship, facing forward); its position off the starboard side indicated great peril for a supertanker that was out of its lanes and accelerating through close waters. Cousins gave right rudder commands to cause the desired course change and took the ship off autopilot. He also phoned Hazelwood in his cabin to inform him the ship was turning back toward the traffic lanes and that, in the process, it would be getting into ice. When the vessel did not turn swiftly enough, Cousins ordered further right rudder with increasing urgency. Finally, realizing the ship was in serious trouble, Cousins phoned Hazelwood again to report the danger - and at the end of the conversation, felt an initial shock to the vessel. The grounding, described by helmsman Robert Kagan as “a bumpy ride” and by Cousins as six “very sharp jolts,” occurred at 12:04 a.m.
Not necessarilyy a bad thing depending on the circumstances. To maintain a steady course on unreps or open water surveying, a novice would look at the helm movements and be torally confused. A good helmsman can anticipate the effects of the next swell or wave.
There are two basic ways of giving the helmsman steering orders to make turns. One is to give rudder commands, for example “starboard ten” In this case the helmsman has no discretion with regards to rudder amount.
The second is to give courses, “Come right, steady on course xxx” In this method the amount of rudder used is left up to the helmsman.
In the case of the Exxon Valdez grounding the third mate claims that the helmsman was given the order "starboard ten’ but according to the report the helmsman did not maintain 10 degrees rudder, instead the helmsman reduced or put on counter rudder on his own.
Because the Kagen was known to be an incompetent helmsman it’s possible the reason he reduced rudder on his own contrary to his orders is that he was concerned that a high rate of turn on the loaded supertanker would make it too difficult to steady up on the new course. Behavior I have observed in other inept helmsman.
Nothing to do with wind, waves, surveying or unrep.
That’s unacceptable behavior and should be immediately corrected. I used the survey and unrep references to illustrate that the helmsman in those jobs maintains a steady course without anyone looking over his shoulder. The wheel is in constant motion. The helmsman is anticipates by observation how the next swell or wave is going to affect course and turns the wheel to meet it. It’s a skill that maybe 15% of ABs who transition from ships on “normal” runs can accomplish. It takes concentration.
The helmsman on the EV would definitely not be in that 15%. If he was as incompetent as reported, he should have been handed a mop and told to stay off the bridge.
You don’t go to sea with the crew you want, you go to sea with the crew you have.
The voyage plan needs to take into account the possibility of crew error. Bridge manning needs to be such that errors will be caught before the ship is put at risk.
That’s why I have said the idea of leaving the third mate alone in the bridge at night to maneuver a supertanker in restricted waters seems absurd. Having an additional, more experienced officer on the bridge at that time would have been more prudent but also more in keeping with SOP.
Yes, if the helmsman can’t do his job he “should” have been fired but very often that doesn’t happen. Especially on what might be seen as an “easy run” where the helmsman would be expected to be either in open ocean or under close supervision.
From the report:
The helmsman indicated that he did not expect the hard right rudder because the vessel was swinging well and he had already used some counter rudder to slow the vessel’s swing
I’m forced to wonder whether Capt. Hazelwood ordered autopilot at that point because he didn’t trust the helmsman.
It’s possible. But one thing, the helmsman that switched to auto was the 8x12 and the unreliable helmsman was the 12x4. So that would mean the captain was anticipating that an untrustworthy helmsman was on his way up. On the other hand the captain might have also been expecting the more experienced second mate.
In any case keeping a ship on course is an easier task than steadying up from high rates of turn but even then the mate can compensate for lack of skill on the helmsman part by giving the necessary counter rudder orders and so forth to steady up or at least knock the ROT down to minimum to where the helmsman can handle it.
Ha! I read the report but that slipped my mind. I think that knocks my theory into a cocked hat.
I ran into this a while ago from the U of Texas:
MODELS OF THREAT, ERROR, AND CRM IN FLIGHT OPERATIONS with regards to CRM in aviation and trapping errors.It is based on how air crews actually work, turns out cockpit crews make a lot of error but almost always catch them before they do any harm.
A serious error category is something that: put the aircraft in what they call an Undesired aircraft state defined as:
the error results in the aircraft being unnecessarily placed in a condition that increases risk.
I would say in this case when the EV was turned directly towards Bligh Reef, the auto pilot engaged, the load up program started and the captain leaving the bridge to a fatigued third mate.
After that point there was very little margin for error.
Here is a diagram from the linked paper:
In the case of the EV you can follow the flow diagram through the “Additional Error” box in the lower half.
Switch “undesirable aircraft state” for “undesirable vessel state” and the EV’s master and crew followed it to the letter until its inevitable conclusion.
At the risk of beating this horse to death, the grounding occurred at 0009. Where the hell was the likely more experienced 12 to 4 mate. 20 to 25 minutes late.
Upthread somewhere a pilot said the captain being below means that the pilot is trusted. But that’s not necessarily the case. For one the captain is trusting if the pilot does make an error that the crew will catch it.
Most of the errors I catch on the bridge in pilot waters are on the crew side to begin with.
Third mate didn’t call him, was going to let him sleep, till 0009 as it turns out.
When the third mate called the captain abeam of Busby the captain asked if the second mate was on the bridge yet, the third mate told him he had not been called.
Another broken link in the chain.
That was probably me. You are correct, it may not be trust in me, but the mate on watch, but I have had captains of tankers leave the bridge in absolute zero viz while navigating in narrow channels, etc etc. I kinda feel that it has to do with the overwhelming amount of paperwork that these understaffed guys have, more then total trust in the third mate.
On of my favorite lines I have ever said was to a Panama Canal pilot with his back to the window in the lake trying to impress the girl he brought along with him. After a polite poke that i thought we were getting very close to a turn, only to be dismissed kind of curtly - I just said " Capt. I just have never gone between 2 red buoys before. " He spun around took a look and gave a 20 deg rudder order.
