Mar 212010

Reef - 1, Maersk Kendal - 0, teaamwork might have been the answer

MAIB’s report on the grounding of the containership Maersk Kendal on the Monggok Sebarok reef in the Singapore Strait on 16 September 2009 presents some all-too familiar problems and a package of lessons to learn. Complacency, lack of voyage planning, failure of bridge teamwork and inadequate awareness of the information being provided by the Singapore Vessel Traffic information service, were contributory factors.

Two items in the report in particular caught MAC’s attention. The first is the role of cultural factors in the bridge team which were also covered in the report on the grounding of chemical tanker Maria M. In that case a abrasive and abusive Italian master resulted in a bridge team that was afraid to challenge, question or advise him. On Maersk Kendall the situation between the British master and an Indian chief officer was very different, they appeared to be on good terms and the master’s standing orders required the bridge team to question the master if in any doubt concerning his actions yet it still didn’t happen.

Says the MAIB report: “Although the master was approachable, he liked to get involved and to do things himself. This type of leadership carries the risk of working in isolation and, when not properly supported by the bridge team, can result in an error going undetected and unchallenged. Although the master, through his standing orders, had made it clear that the OOW should question the master’s actions when in doubt, this did not infer that the master would first discuss his intentions with the OOW. The master had not convened a bridge discipline meeting since joining the vessel on 17 August 2009 to clarify and reiterate his requirements, and it is evident that the chief officer considered it unnecessary to question the master’s intentions or actions on this occasion.

“Different societies vary in the way inequalities in status and power are handled. In societies organised on relatively authoritarian or paternalistic lines, consultation between superiors and subordinates is not expected (by either party). The probability of a subordinate challenging or contradicting a superior’s decision is low. A respected superior is treated as more or less infallible. In a less authoritarian society, the emotional distance between leaders and those led is smaller and thus the barriers to consultation and co-operative decision making are less formidable.

”Hofstede and Hofstede (2005) have measured the strength of these attitudes and expectations in many countries in the form of a Power Distance Index. Countries in the Indian sub-continent tend to have a higher Power Distance Index than countries in northern Europe. In a worldwide study of 74 countries, India scored 77, while the United Kingdom scored 35 on the Index, which suggests markedly different approaches to power and status”.

While there have been criticisms of the Hofstede Power Distance Index it remains a useful indicator to be used with caution. In the Maria M case, for instance, Italy, the nationality of the master, has a PDI of 50 while the Philippines, the nationality of the third officer, is 94. On the bridge of the Cosco Busan, where similar cultural elements were at work, the nationality of the pilot was American, which has a PDI of 40 while the master was from China, which has an estimated PDI of 80.

A second item of interest is the highlighting of VDR data as a preventative tool rather than just an accident investigation tool. Doing so may overcome the common problem of VDR data not being saved due to unfamiliarity.

image Says the report: “The master was not familiar with the working of a VDR and had never saved data on it before. He initially reported to the company that the VDR data had been saved. However, when it was established some time later that the yellow light, which was designed to remain lit to indicate that the data had been saved, had not illuminated, he should have sought advice from the company. He could have either stopped power to the VDR unit or simply removed the hard drive to prevent it from being overwritten.”

image When a company auditor is aboard there is a very good chance that the bridge team will be on its best behaviour and the auditor’s observations may not match the way the bridge usually functions.

Says MAIB: “..evaluations of VDR data taken from vessels following accidents have provided the MAIB with invaluable evidence on how vessels normally operate away from the scrutiny of company officials. Reluctance to follow procedures, and complacent attitudes, can be identified and addressed by monitoring the activities of ship staff during random audits of VDR data.

EU directive 2009/18/EC7 not only encourages the use of VDR data for accident investigation but also as a preventative tool. The directive advocates the routine examination of VDR data by ship managers to gain experience of the circumstances capable of leading to accidents or incidents. Such examination will provide them with incontrovertible information on watchkeeping standards under normal operating conditions.”

Random audits of VDR data can identify existing problems and track developing issues that could contribute to an incident, enabling companies to identity and mitigate them. It would enable training managers to make more efficient use of their training budgets by identifying the training needs of specific individuals – if 10 officers have good Bridge Team/Crew Resource Management skills and two do not then it is more cost effective to focus BTM/CRM training on those who need, and a magnitude more cost effective than training them after an incident.

It would also give officers more familiarity with the equipment, and the right button to push when an incident does occur.

The full MAIB report is available here


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