Maritime Investigation Report: Grounding of Bulk Carrier Munos
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Michael Kushla
13 March 2018
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Summary of casualty.
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Vessel Parameters.
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Onboard navigational systems.
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Timeline.
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Original Passage Plan vs. amended Passage Plan.
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MAIB conclusions.
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MAIB Action Item.
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The Prudent Mariner (with takeaways).
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Heinrich’s Domino Theory (with takeaways).
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Effect on NIPWG and HOs.
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Muros enroute from Teesport, United Kingdom to
Rochefort, France with a cargo of bulk fertilizer.
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Original Passage Plan—Transit via North Hinder
Junction.
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Amended Passage Plan—Transit via Sunk Traffic
Separation Scheme.
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Vessel aground on Haisborough Sand on early
morning of 3 December 2016 on a falling tide.
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Vessel refloated on 9 December 2016.
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Vessel towed to Rotterdam, Netherlands to repair
rudder damage.
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Vessel name:
Muros
Flag:
Spain
Size:
2,998 gross tons
Length overall:
89.9 meters
Draft:
6.03 meters (forward)
6.13 meters (aft)
Cargo:
Bulk fertilizer
Crew:
Nine
Last port:
Teesport, United Kingdom
Next port:
Rochefort, France
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1. ECDIS (Marine Navigation System
AB Type ECDIS 900 (MARIS ECDIS900)
Mk 10)—Functioning correctly.
2. Vessel navigated on Electronic
Navigation Charts supplied by PRIMER,
operated by the Norwegian Hydrographic
Service.
3. The vessel did not carry paper charts.
4. Radar—Functioning correctly.
5. Bridge Navigational Watch Alarm
System (BNWAS)—Functioning correctly.
Set to alert at 3-minute intervals.
6. Echo sounder—Switched off after
departing Teesport.
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2-3 December 2016
2000-0010
Master on bridge.
Autopilot steering.
Course: 146⁰.
Speed: 11.2 knots.
Transit via North Hinder Junction.
2 December 2016
2350
Second Officer (2/O) on bridge to relieve Master.
2-3 December 2016
2350-0010
Watch handover from Master to 2/O.
Master instructed 2/O to amend Passage Plan to transit via
Sunk Traffic Separation Scheme vice original transit via
North Hinder Junction.
3 December 2016
0025
2/O adjusted autopilot steering to 140⁰ based on amended
Passage Plan.
0208
2/O adjusted autopilot steering to 146⁰.
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3 December 2016
0220
2/O noticed speed on ECDIS display reduced from 10.2
knots to 9.1 knots.
0228
2/O noticed change in ship’s motion and speed reduced to
0.8 knots.
Shifted to manual steering.
Notified Master.
0229
Master and Chief Engineer on bridge.
0330
Vessel firmly aground on a heading of 190⁰.
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Humber Coastguard notified about vessel grounding.
0930
Unsuccessful attempt to refloat vessel at High Water.
4 December 2016
Morning
Salvors arrived.
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9 December 2016
Unknown
Vessel refloated and towed clear of Haisborough Sand.
Vessel towed to Rotterdam, Netherlands for repairs to
rudder.
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The amended Passage Pass was inherently unsafe.
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ECDIS system and procedural safeguards intended to
prevent groundings overlooked, disabled, or ignored.
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Visual check of amended Passage Plan by 2/O did not
identify the unsafe track over Haisborough Sand.
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The track of the amended Passage Plan not planned or
checked on an appropriate scale chart.
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The use of the “standard” chart view limited the display
of information and allowed the reliance upon visual
checks when passage planning to be prone to error.
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Audible alarms were disabled and the guard zone
removed.
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The ECDIS not used as expected by the regulators or
the equipment manufacturers.
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Amending the Passage Plan interfered with the
watchkeeping duties of the 2/O.
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Master did not check or approve the amended Passage
Plan.
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Time of day and fatigue may have reduced the
effectiveness of the 2/O.
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A joint safety study to be conducted by the United
Kingdom Marine Accident Investigation Branch and
the Danish Maritime Accident Investigation Board
with the following emphasis:
Why mariners use ECDIS in ways not in accordance with
instructions and guidance provided by system
manufacturers and regulators.
Provide comprehensive data to improve functionality of
future ECDIS systems.
Use this data to encourage greater use of operator
experience and human-centered design principles.
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“The Prudent Mariner will not rely solely on and
single aid to navigation, particularly a floating aid.
An aid to navigation also refers to devices or
structures external to a vessel which are designed to
assist in the determination of position, including
celestial, terrestrial, and electronic means, including
Global Position Systems (GPS) and Differential GPS
(DGPS).”
U.S. Special Paragraph No. 1 of 2018
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ECDIS is one Aid to Navigation (ATON).
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Echo sounder is a second ATON.
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Echo sounder not being operated (based on MAIB Report).
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Compare the results of a “soft grounding” at a speed
approaching 0 knots with the “hard grounding” which began
at a speed of 11.2 knots.
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“Accidents resulting from a chain of sequential events,
metaphorically like a line of dominoes falling over.
When one of the dominoes falls, it triggers the next
one, and the next … —but removing a key factor (such
as an unsafe condition or an unsafe act) prevents the
start of the chain reaction.”
Disaster Management Institute, Bhopal
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Big Domino #1—Amended Passage Plan:
Water depth = 5.0 to 6.2 meters.
Maximum draft = 6.16 meters.
Guaranteed grounding situation.
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Big Domino #2—Process of amending the Passage
Plan:
Occurred during and slightly after the watch handover.
Conflict between watchstanding duties and process of amending the
Passage Plan.
Potential 2/O fatigue affecting procedures for amending the Passage
Plan.
If proper ECDIS procedures were followed, resulting in the elimination of one
of the “dominoes” described in the MAIB Report conclusions, the grounding
could have been avoided.
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The nautical information provided by HOs for display on an
ECDIS (or in another other distribution method) must be
accurate, timely, and relevant.
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Providing accurate, timely, and relevant nautical information
will lessen the chance of HO failures being one of the
“falling dominoes.”
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Version 8; 28 Feb 2011; 4:15 PM
Investigation report by the UK Maritime Accident Investigation Branch on the grounding of the bulk carrier Munos off the East Coast of England in December 2015. The report includes details on the casualty, vessel parameters, onboard navigational systems, a timeline of events leading to the grounding, and conclusions drawn by the MAIB. The report also highlights action items, safety considerations for mariners, and the impact on maritime practices.
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Presentation Transcript
UNCLASSIFIED United Kingdom Maritime Accident Investigation Branch (MAIB) Report 22/2017 Grounding of Bulk Carrier Munos off the East Coast of England on 3 December 2015 Michael Kushla 13 March 2018 1 1
UNCLASSIFIED Agenda Summary of casualty. Vessel Parameters. Onboard navigational systems. Timeline. Original Passage Plan vs. amended Passage Plan. MAIB conclusions. MAIB Action Item. The Prudent Mariner (with takeaways). Heinrich s Domino Theory (with takeaways). Effect on NIPWG and HOs. 2
UNCLASSIFIED UNCLASSIFIED Summary of Casualty Muros enroute from Teesport, United Kingdom to Rochefort, France with a cargo of bulk fertilizer. Original Passage Plan Transit via North Hinder Junction. Amended Passage Plan Transit via Sunk Traffic Separation Scheme. Vessel aground on Haisborough Sand on early morning of 3 December 2016 on a falling tide. Vessel refloated on 9 December 2016. Vessel towed to Rotterdam, Netherlands to repair rudder damage. 3
UNCLASSIFIED Vessel Parameters Vessel name: Flag: Size: Length overall: Draft: Muros Spain 2,998 gross tons 89.9 meters 6.03 meters (forward) 6.13 meters (aft) Bulk fertilizer Nine Teesport, United Kingdom Rochefort, France Cargo: Crew: Last port: Next port: 4
UNCLASSIFIED Onboard Navigation Systems 1. ECDIS (Marine Navigation System AB Type ECDIS 900 (MARIS ECDIS900) Mk 10) Functioning correctly. 2. Vessel navigated on Electronic Navigation Charts supplied by PRIMER, operated by the Norwegian Hydrographic Service. 3. The vessel did not carry paper charts. 4. Radar Functioning correctly. 5. Bridge Navigational Watch Alarm System (BNWAS) Functioning correctly. Set to alert at 3-minute intervals. 6. Echo sounder Switched off after departing Teesport. 5
UNCLASSIFIED Timeline Date Time Event 2-3 December 2016 2000-0010 Master on bridge. Autopilot steering. Course: 146 . Speed: 11.2 knots. Transit via North Hinder Junction. 2 December 2016 2350 Second Officer (2/O) on bridge to relieve Master. 2-3 December 2016 2350-0010 Watch handover from Master to 2/O. Master instructed 2/O to amend Passage Plan to transit via Sunk Traffic Separation Scheme vice original transit via North Hinder Junction. 3 December 2016 0025 2/O adjusted autopilot steering to 140 based on amended Passage Plan. 0208 2/O adjusted autopilot steering to 146 . 6
UNCLASSIFIED Timeline (continued) Date Time Event 3 December 2016 0220 2/O noticed speed on ECDIS display reduced from 10.2 knots to 9.1 knots. 0228 2/O noticed change in ship s motion and speed reduced to 0.8 knots. Shifted to manual steering. Notified Master. 0229 Master and Chief Engineer on bridge. 0330 Vessel firmly aground on a heading of 190 . 0357 Humber Coastguard notified about vessel grounding. 0930 Unsuccessful attempt to refloat vessel at High Water. 4 December 2016 Morning Salvors arrived. 7
UNCLASSIFIED Timeline (continued) Date Time Event 9 December 2016 Unknown Vessel refloated and towed clear of Haisborough Sand. Vessel towed to Rotterdam, Netherlands for repairs to rudder. 8
UNCLASSIFIED Comparison of original Passage Plan with amended Passage Plan 9
UNCLASSIFIED Conclusions from United Kingdom MAIB Report 22/2017 The amended Passage Pass was inherently unsafe. ECDIS system and procedural safeguards intended to prevent groundings overlooked, disabled, or ignored. Visual check of amended Passage Plan by 2/O did not identify the unsafe track over Haisborough Sand. The track of the amended Passage Plan not planned or checked on an appropriate scale chart. The use of the standard chart view limited the display of information and allowed the reliance upon visual checks when passage planning to be prone to error. 10
UNCLASSIFIED Conclusions from United Kingdom MAIB Report 22/2017 (continued) Audible alarms were disabled and the guard zone removed. The ECDIS not used as expected by the regulators or the equipment manufacturers. Amending the Passage Plan interfered with the watchkeeping duties of the 2/O. Master did not check or approve the amended Passage Plan. Time of day and fatigue may have reduced the effectiveness of the 2/O. 11
UNCLASSIFIED MAIB Action Item A joint safety study to be conducted by the United Kingdom Marine Accident Investigation Branch and the Danish Maritime Accident Investigation Board with the following emphasis: Why mariners use ECDIS in ways not in accordance with instructions and guidance provided by system manufacturers and regulators. Provide comprehensive data to improve functionality of future ECDIS systems. Use this data to encourage greater use of operator experience and human-centered design principles. 12 12
UNCLASSIFIED The Prudent Mariner The Prudent Mariner will not rely solely on and single aid to navigation, particularly a floating aid. An aid to navigation also refers to devices or structures external to a vessel which are designed to assist in the determination of position, including celestial, terrestrial, and electronic means, including Global Position Systems (GPS) and Differential GPS (DGPS). U.S. Special Paragraph No. 1 of 2018 13 13
UNCLASSIFIED Takeaways from The Prudent Mariner Concept ECDIS is one Aid to Navigation (ATON). Echo sounder is a second ATON. Echo sounder not being operated (based on MAIB Report). Critical navigation safety information (depth under the keel) from a second ATON was not available to watchstanders. Compare the results of a softgrounding at a speed approaching 0 knots with the hardgrounding which began at a speed of 11.2 knots. 14 14
UNCLASSIFIED Heinrich s Domino Theory Accidents resulting from a chain of sequential events, metaphorically like a line of dominoes falling over. When one of the dominoes falls, it triggers the next one, and the next but removing a key factor (such as an unsafe condition or an unsafe act) prevents the start of the chain reaction. Disaster Management Institute, Bhopal 15
UNCLASSIFIED Takeaways from Heinrich s Domino Theory Big Domino #1 Amended Passage Plan: Water depth = 5.0 to 6.2 meters. Maximum draft = 6.16 meters. Guaranteed grounding situation. Big Domino #2 Process of amending the Passage Plan: Occurred during and slightly after the watch handover. Conflict between watchstanding duties and process of amending the Passage Plan. Potential 2/O fatigue affecting procedures for amending the Passage Plan. If proper ECDIS procedures were followed, resulting in the elimination of one of the dominoes described in the MAIB Report conclusions, the grounding could have been avoided. 16
UNCLASSIFIED UNCLASSIFIED How This Affects NIPWG and HOs The nautical information provided by HOs for display on an ECDIS (or in another other distribution method) must be accurate, timely, and relevant. Providing accurate, timely, and relevant nautical information will lessen the chance of HO failures being one of the falling dominoes. 17
UNCLASSIFIED UNCLASSIFIED 18 18 UNCLASSIFIED
