This podcast has a special place in MAC’s heart – it was the very first one ever broadcast. At the time we did not have a video production capability or a recording studio so the sound quality may be least than ideal but the lessons remain very current.
An exhausted Captain; single watch-keeping; a warm, cozy bridge at night; the heavy traffic of the Kiel Canal, and pirated navigational software. If you think that sounds like a recipe for disaster, you’d be absolutely right.
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We’ll call him John, it’s not his real name. He joined the shipping company in 1999 as a Chief Officer. In 2004 the UK Maritime and Coastguard Agency issued a certificate of equivalent competency. This allowed him to sail on British-flagged ships as a master. Later that year he took his first trip as a relief master, with a second turn as relief master in February 2005. All in all he’d spend five months as a relief master before boarding a new vessel on July 18th 2005. For the first time in his career, he was master of his own ship.
She was the Lerrix, a 73 and a half metre long general cargo vessel of 1989 gross tonnes built in 1976.
She had a crew of seven. Registered in Hull under the British flag she had previously been flagged in Bermuda. Why that was important we’ll see in a moment.
The navigational aids on the bridge were basic, but complied with statutory requirements: There were two radars, neither had an automatic radar plotting aid, or ARPA, capability. There was a stand-alone Global Position System receiver to identify the ship’s position, and an Automatic Identification System, or AIS, which transmitted the vessel’s identity and position to others in the area and displayed the name and position of similarly equipped vessels on a screen aboard the Lerrix. John felt that another piece of equipment would be useful: an Electronic Chart display. There wasn’t one on the bridge so he brought his own. When he boarded the Lerrix he mounted his personal GPS receiver on the bridge console and plugged it into a laptop computer which he placed in front of a comfortable chair. This was used by himself and the officer on watch.
The navigational software was made by Transas, a much respected provider based in Russia. Although there are several cheap, and sometimes free, navigational software products available, the software in John’s laptop was a pirated version he had downloaded from the internet. It hadn’t been updated for six years. It didn’t have the way-point, cross track and other alarms that legitimate navigational software offers.
John’s informal navigational aid did not breach company regulations because at the time the company did not have any regarding personal navigational equipment. The company regulations were well behind technology developments, and didn’t take account of the fact that personal electronic navigational systems cost little more than a night out on the town.
So, at 21.00 hours October 8, 2005, with John as the Officer on Watch, the Lerrix left the Alexandra Dock in Hull, sailed downriver and at 23.00 set a course across the North Sea to the River Elbe and the Kiel Canal. She was laden with second hand cars and containers bound for Klaipeda, Lithuania, on the Baltic Coast.
At midnight, John handed the watch over to the first mate and went below to take his six-hours rest. He didn’t get much sleep. Several times he woke up, lit up a cigarette and drank coffee as he watched the traffic on the Elbe pass by. Weighing heavily on his mind was distress at the death of a colleague two weeks before, a loss which he had yet to come to terms with.
John relieved the First Mate at 06.00 and at 07.45, with a pilot aboard, entered the Kiel Canal. Nothing remarkable happened for the next few hours and at 12.00 hours he was relieved by the First Officer again went below for lunch then put his feet up for a few hours. But he didn’t get much rest: At 13.00 and 14.00 he went to the bridge to check on the vessel’s progress and at 15.00 he went to the bridge as the ship entered the final lock on the Kiel Canal. About a half hour later the vessel left the Kiel Canal and commenced the last leg of her journey to Lithuania. John went below again at 16.45 for supper.
When John returned to the bridge at 18.00, in darkness, he brought with him a burden of fatigue that had built up since leaving Hull. He opened the bridge door to take away the smoke for his cigarettes and chugged coffee to keep going. Even so, it didn’t show. The ship’s AB/Cook arrived on the bridge at 19.45 for lookout duty and didn’t see anything amiss with the John’s behaviour.
The cook had never been briefed on the seriousness of lookout duty. If he had, he might have approached his task with more enthusiasm but he had something on his mind. He was due to leave the Lerrix the next day and he wanted to hand over a clean gallery to his relief. His job on the bridge was to be a lookout, but he saw his real job as being a clean cook.
For the next two and a half hours the two men chatted until, sometime between 22.30 and 23.00 hours he requested permission to clean the galley. John agreed. It was probably the worst decision of his career.
What John didn’t know is that the bridge watch alarm wasn’t working. A watch alarm sets off an alert at intervals, pushing a button on the bridge switches off the alarm until the next interval. The idea is to make sure that someone is awake on the bridge.
He didn’t know the Lerrix watch alarm was disconnected because in the nearly three months he’d commanded the vessel, he hadn’t discovered that the Lerrix had a watch alarm. He didn’t know that because the watch alarm button hadn’t been marked. It was something anonymous on the console that nobody bothered to ask about.
Under the Bermuda registry, if two or less ABs are on the bridge, a watch alarm must be fitted. When the vessel switched to the British registry the AB compliment on the bridge was increased to three and the watch alarm was no longer a statutory requirement.
Alone on the warm, darkened bridge, in a comfortable chair, with the glow of the laptop and its crippled navigational software, and an unknown and disconnected bridge watch alarm, and the gentle, soothing movements of the vessel, John feel asleep with the ship on autopilot.
For all practical purposes, the vessel was now NUC, not under command.
As John slept soundly for the first time since leaving the Alexandra Dock more than a day before, the vessel headed for the Darss Peninsular on the German Coast.
The vessel missed a course alteration, left its traffic lane and headed for dry land.
German Traffic control at Warnemunde realised something was wrong. A patrol launch, the Arkona, was sent to investigate. VHF calls to the errant vessel went unanswered. She sailed silently like the Mary Celeste. The Lerrix (Yellow circle) ploughs towards the coast as the patrol boat Arkona (Red circle bottom left) races to intercept. <!–[if !supportMisalignedRows]–>
The grounding was not very dramatic. In fact, when it came at 23.42, it was so gentle, no-one on the ship noticed, least of all our cozy captain. She just drove herself up the beach at full power and went on doing so for nearly 18 more minutes. The cook, who was showering at the time, didn’t notice, nor did the First Mate who was preparing for his watch at midnight.
A few seconds before midnight, John woke up, saw the radar in front of him and hauled the engine telegraph to full astern. Engine room alarms sounded as the First Mate entered the bridge. But the Lerrix was aground.
Nobody was hurt, there was no pollution, and only the vessel’s paintwork was damaged, although it probably wasn’t a great career move for John on his first full command.
The Fatigue Factor
John’s problem was fatigue. As a Master, fatigue comes with the territory, yet it’s something for which there is little training or preparation. Mandated rest periods and drinking coffee simply aren’t enough, it’s also a matter of using available resources to combat fatigue. There is a need for training in fatigue countermeasures but unless it is made mandatory, it isn’t likely to happen.
When he let the lookout leave the bridge, John was without the support he needed simply to keep awake and alert. It was a bad decision; indeed, the official Maritime Accident Investigation Branch report called it ‘irrational’, typical of fatigue. A sleepy captain was now on watch alone. Once he had made that decision, everything else, from the unknown watch alarm to the mute pirated software fell into place and made the grounding all but inevitable.
Doing The Numbers
If ‘all but inevitable’ sounds presumptuous consider this: In a Maritime Accident Investigation Branch study of 66 selected incidents involving 75 ships over nine years, one third had a fatigued officer on the bridge alone. The Lerrix had a fatigued officer on the bridge alone. In two thirds of the incidents no proper lookout was being kept. The Lerrix was not keeping a proper lookout. A third involved a sole watcher on the bridge at night. There was only one man on watch on the bridge of the Lerrix that night. If you’re maths smart, you’ll notice that all comes to one and a third, the Lerrix fitted the profile a little more than 130 per cent.
Fatigued Officer on bridge – 33%
No Proper Lookout – 66%
Single Watchkeeper – 33%
Putting a crew on a ship costs a lot of money and the industry is very cost sensitive. Manning is the biggest single cost factor in this very competitive environment. On some vessels, like the Lerrix, costs are trimmed by utilising the master as a watchkeeper, alternating with the chief officer. According to the Maritime Accident Investigation Branch report on the Lerrix, ships of under 3,000 gross registered tonnes, like the Lerrix are more likely to be involved in a grounding.
Fatigue will remain a factor in maritime accidents for the foreseeable future. So how do we deal with it? First, accept the reality of fatigue and take defensive measures.
There are certain times in a passage when a master must be on the bridge whether or not it’s his rest period, examples in this case were the entrance and exit to the Kiel Canal. Look at the passage plan, identify those events and try to allow for them in scheduling watchkeeping routines. If you can, schedule the night watch so you’re off the bridge and resting before sunrise, you’ll have a better chance of getting real sleep.
If you’re not getting fully rested, or like John under additional personal stress, don’t just try to ‘cope’, take positive measures. Drinking coffee can help for a while but if lack of rest and stress continues, as it did with John, you’re building up a fatigue debt that will have to be paid and it can make matters worse. Better still, drink water or fruit juices.
Avoid Being Alone, Stay Active
At night, try to avoid being on the bridge alone. If you do have to be alone, use the watch alarm. Don’t make yourself too comfortable, because that’s what your fatigue is waiting for. Find means to maintain mental stimulation: Don’t sit there with nothing to do and stare at a glowing computer screen as John did. Make-work if you have to, check positions, take star sights, renew your acquaintance with the sextant, in fact anything that keeps you moving and your mind working Keep physically and mentally active.
You might take a tip from the movie industry, which is is also subject to the rigors of working at night in a stressful environment: have breakfast as the first meal of your working day, whenever than day begins. If your first watch is at 6pm, have a breakfast-type meal: bacon, eggs, cornflakes, whatever you would normally have at the start of the day. It’ll set off some psychological and physiological triggers that can help you maintain alertness.
And you can increase your resistance to fatigue by rest, exercise and a balanced diet. We’ll be looking at those issues in the future.
As for John’s snaffled and silent software, well, would you want a pirate on your bridge?
If you have have opinions on this, or any other Maritime Accident Casebook, episode, or want to share your experiences, go to http://maritimeaccident.org.
This is Bob Couttie wishing you safe sailing.