May 312010


In the midst of a critical turn on 16 August 2007 to take the vessel into a channel between Entrée Island and Schooner Island the OOW of the Canadian ferry Nordic Express sent the helmsman from the bridge to call the docking crew to stations. The OOW took over the helm, a position from which he could not see the radar or the Electronic Chart Display, ECS.

Over the next two minutes the OOW had problems controlling the turn. By the time the helmsman returned to the bridge the vessel was on the desired heading but on a parallel track offset to the north east and heading for Entrée Island full-ahead.

image Checking the ECS, the OOW gave avoidance orders as the helmsman, seeing the lights of the island ahead, took independent avoiding action.

Nordik Express struck Entrée Island then proceeded across the channel towards Schooner Island, where it almost grounded. The vessel berthed with a significant list under command of the master at Harrington Harbour with significant damage.

Of ironic note in the report is that the OOW has apparently self-medicated with Lorezapam which had not been prescribed for him in order to ensure he got enough sleep to carry out his duties. Says the Transportation Safety Board of Canada: “This drug is used to treat anxiety disorders and insomnia due to anxiety or transient situational stress. Its main side effect is drowsiness. Lorazepam affects the central nervous system and patients are cautioned that the medication may impair mental or physical abilities required for the performance of potentially hazardous tasks requiring mental alertness, such as operating a motor vehicle or machinery.”

To put its potential effects into context, Lorezapam is used by the so-called ‘Ativan Gangs’ in South East Asia to drug victims for robbery.

Self-medication without doctor’s advice and knowledge of the medicine’s side-effects is unwise. The OOW had not told the master that he had taken the medication, which was required by company policy.

Canada’s TSB does not make an overt causal link between the OOW’s medication and the events of 16 August 2007.

The master, who was not part of the watch rotation, gave verbal orders to be called 30 minutes before arrival, which would have enabled him to be on the bridge well before the start of the critical turn. For reasons unknown, the OOW did not call him until 20 minutes after the call time and just before the critical turn.

With no written standing orders or notes on the chart or ECS, there was an appreciable risk of the instructions being overlooked or forgotten.

image Passenger handling after the strikes was largely ad hoc. Says the TSB report: “…

bridge crew focused all their attention after the striking on conning the vessel to the dock. They did not transmit an urgency or distress call, nor was an alarm sounded or any other communication made from the bridge to the passengers or crew members. Moreover, calls to the bridge from the engine room crew were unanswered.

Crew members’ response, therefore, was improvised and a number of shortcomings were observed:

  • The crew did not ensure that passengers arrived at the muster station in an appropriate state of dress for a possible evacuation.
  • There was no systematic search of passenger cabins.
  • There was no count taken of passengers at the muster station.
  • The crew did not seek guidance/instruction from the bridge.
  • Passengers were not provided information about the situation.
  • The distribution of lifejackets was disorganized.

Given that previous training and drills, as well as written emergency plans, always commenced with the sounding of an alarm, the lack of an alarm likely caused confusion as to how to react, thereby playing a key role in the aforementioned shortcomings. In addition, the lack of an alarm precluded the heightened mental and physical preparedness that could save crucial time in the event that the unpredictable situation took a turn for the worse.

Passengers, meanwhile, having received little information regarding the emergency and what was expected of them, displayed signs of confusion and anxiety. Literature concerning human behaviour in emergencies indicates that anxiety and stress in a crowd increase when people are not provided with information. Combined with physical indications of danger-such as loud noise, the sensation of impact, the smell of smoke, and the list of a vessel-the risk of counterproductive behaviour or panic is increased.”

Two issues relevant to the listing of the ship include confusion regarding the instructions for the use of the cross-over valves, which conflicted with onboard practice, and the practice of sailing with water-tight doors open which conflicted with TSB recommendations.

Says the report: “…some Canadian operators continue to operate their vessels with watertight doors open, thereby placing vessels, passengers, crews, and the environment at undue risk." In response, TC noted that the Hull Construction Regulations already state that all watertight doors are to be kept closed at all times while a ship is in operation.45 Moreover, TC noted that it has previously issued ship safety bulletins regarding watertight doors and that it plans to monitor and participate in ongoing International Maritime Organization (IMO) development of related guidelines.

It is recognized that practices and procedures related to watertight doors are situational and ship-specific, and therefore not easily regulated. However, operating with watertight doors open at all times exposes the vessel, its crew, and passengers to undue risk. It is therefore incumbent on crews and operators to carefully consider their practices and procedures in this regard to ensure that this risk is minimised.”

The full report is available here.

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