“Pilot complacency syndrome” (61 - f, page 20). Have always thought that complacency by its very nature unlike other “states of mind” (rushing, fatigue and frustration) is not as easy to identify in real time and therefore more difficult to guard against. For all the formality of this reporting format (findings of fact, opinion, recommendations) it doesn’t seem to square with other industry approaches to incident investigation. Root cause, Swiss cheese, fish bone whatever you want to call them. This was standard at TOI once upon a time anyway. http://www.kelvintopset.com/about/root-cause-analysis
Those MERCY class ships are horrid to handle. I was on COMFORT and we had a few close calls. The deck equipment is wasted, the sail area is huge, it has no thrusters, it’s steam, single screw and visibility from the bridge is severely limited. The crews are cobbled together on short notice and don’t sail together for long. The ships don’t even get underway often.
That they only almost hit the ARIZONA Memorial isn’t surprising. We almost ran our stern aground on two occasions in a month, almost sucked our lines into the screw a few other times. That was the only ship I’ve been afraid to go on maneuvering detail.
[QUOTE=DeckApe;175752]Those MERCY class ships are horrid to handle. I was on COMFORT and we had a few close calls. The deck equipment is wasted, the sail area is huge, it has no thrusters, it’s steam, single screw and visibility from the bridge is severely limited. The crews are cobbled together on short notice and don’t sail together for long. The ships don’t even get underway often.
That they only almost hit the ARIZONA Memorial isn’t surprising. We almost ran our stern aground on two occasions in a month, almost sucked our lines into the screw a few other times. That was the only ship I’ve been afraid to go on maneuvering detail.[/QUOTE]
I am continually bombarded with the concept of “risk assessment” in my shipboard life. I wrestle with how much, how good, why and what is the final value of the risk assessments done everyday on almost every job. At times I wonder whether the nearly arbitrary numerical assignments of “likelihood” and “consequence” to get a number so we can come up with things to lower the number to safe levels is in a way increasing overall risk of operating by virtue of mandating participation in a system of questionable value. Lest the safety professionals misunderstand me, of course identifying hazards and then coming up with preventive and mitigating controls has complete and total value even back when this process was accomplished completely between the ears of the officers and crew.
But DeckApe your words above seem to me to be a most eloquent statement of risk. The actions one might devise to control those risks seem obvious even to this engineer. At the very least use the normal amount of tugs. They should have had you do the investigation.
Only one (no. 13) of the 18 “opinions” addresses the bum’s rush they were giving the ship and that opinion only says the captain and pilot “accepted the risk inherent” in departing with 2 instead of 3 tugs originally requested. Surely port control (or whatever entity was giving orders is called) is aware of the same ships and operational characteristics you mention and instead of essentially (and literally as it turns out) backing these guys into a corner for the sake of a change of command ceremony could have taken some management decisions to avoid the situation.
The closest they come to teasing out what might be considered a root cause are two of the recommendations(14 and 15)where they say the results should be reviewed by the people in charge of the pilots and the contracted tugs so they might identify any corrective actions they could take. How about recommending looking at the wisdom of ordering them out of port in an accelerated schedule, in what seems to be tight quarters with multiple ships sailing so all tugs could be back in their berths and secured for the ceremony?
I am not questioning the validity of all the recommendations. Indeed it does appear there were some instances of poor performance by the shipboard team. Easy for me to say I wasn’t there but is the installation of weatherproof ECDIS repeaters on the bridge wings (recommendation no. 9)really a good idea? Can that substitute for an experienced team performing the normal roles when departing a port and maneuvering out?
To be sure they do address personnel issues but what will they do with that information? Retaining experienced chief mates is a good idea but more BRM (if it is anything like ERM)wouldn’t have saved the day in this case. More experience performing the tasks involved would have. I didn’t detect any hesitancy of the deck officers in reporting problems to authority it seems more like they didn’t see the problems or realize what they were seeing were problems, except the poor guy on the fantail.
While the report itself is only 38 pages of the 378 some interesting info in the enclosures. Namely the masters standing orders (pages 99 to 123) especially section 7 and 8 (120 to 123). This does not appear to be completely boilerplate or written / issued by an inexperienced captain. Gave me a few ideas to tune up my own in terms of style and few other things.
The “navigational brief checklist” at page 124, requested 3 tugs, addresses calling out distances.
Thanks for posting the link (Polaris) and your insight to this class of ship (DeckApe).
When Mercy’s sister ship, Comfort, was new she nailed a fuel pier. This was way before any BRM classes, ECDIS or anything else. The Navy bought junk and this junk has had issues since day one. No amount of fancy equipment or BRM classes is going to make these ships perform any better.
Root causes IMO:
- Failure of the seaman’s eye to detect sternway.
- Turning short when they could have backed up a little more and had a lot more room.
- Leaving the rudder hard right.
- Full power on the forward tug.
- Tug on a bad angle.
The C/M and 2/M got thrown under the bus. Only in a perfect world would junior officers have the situational awareness to save this.
Good read. I was on it the year before so I know many of the officers onboard.