LESSONS LEARNED FROM INCIDENT INVESTIGATION

ID: AS/012/2020 COLLISION WITH FISHING BOAT IN GIBRALTAR STRAIT TSS

Incident One of our Bulk Carrier was navigating inside the Traffic Separation Scheme
Description off “Banco del Hoyo” on western limits of Gibraltar strait. Bridge watch
composition was maintained at level 2 with Second Officer and Duty AB.
(What happened): Weather and visibility conditions at the time of incident were good.

At around 00:44 LT during night watch, Second Officer spotted a target on

RADAR approaching from port side and discussed with duty AB. Duty AB
visually sighted the vessel and as per the lights visible, target was recognized
as vessel engaged in trawling.

Second officer and duty AB continued to monitor the target vessel on RADAR
as well as visually. ARPA data of the target indicated very small CPA, about
0.2 NM or less and small BCR (bow crossing range), about 0.3 NM or less.
CPA and BCR data on ARPA remained very low throughout with ARPA
display continuously alarming.

It was noted that bridge team, despite monitoring the target closely, was
unable to appreciate the developing risk of collision. Collision warning on
ARPA display was ignored and no early action was taken to allow safe
passing.

It was noted from communication between Second officer and duty AB that the
bridge team, at no point in time decided to take action to keep clear of Fishing
Vessel and were rather waiting for fishing vessel to keep clear of own vessel.
It was also noted that bridge team was engaged in non-navigation related
discussion continuously for some time during critical stage of risk of collision.

Few seconds before the collision, when collision was imminent with target
vessel less than half cable away on port side, Second officer ordered duty AB
to change over to hand steering and alter to starboard. This late action was
not adequate for vessel to prevent collision and own vessel collided with
Fishing Vessel.
 Own vessel suffered bold scratches on port side hull while fishing vessel
suffered damage to two decks on bow as reported by traffic control. After
ascertaining that none of the vessel were in any imminent danger, both
vessels continued the voyage after the collision.

There was no injury, loss of life or pollution due to the above incident.

Photos:

Potential This incident, in slightly different circumstance, could have led to serious
Outcome damage to fishing vessel, possible loss of life and serious hull damage to own
(What else could vessel. Such incidents, if resulting into serious consequence, could also lead
have gone to imprisonment of officers involved and suspension of license.
wrong):
Immediate Unsafe Act: Incorrect navigation / ship handling
Causes: - Assessment for Risk of Collision was inadequate which led to poor
judgment and no action at all.
- No attempt was made to attract the attention of fishing vessel to avoid
close quarter situation.
- Non-compliance of rule 10 by the fishing vessel

Root / Basic Poor risk awareness / perception of risk: Although the Duty officer was
Causes: monitoring the target on RADAR / ARPA and visually for nearly 28 minutes
before the collision, he was unable to ascertain that risk of collision existed.
Human Factor: CPA and TCPA alarm on RADAR/ARPA equipment was ignored and action
was not taken well in time.

Corrective/ 1. Training was conducted onboard to familiarize all deck officers once again
Preventive to learn Navigational procedures laid in AE SMS manual NMM.
Measures: 2. Extraordinary QHSE Meeting was conducted on board with entire crew on
subject of the incident occurred and lessons learnt.
3. Further evaluation of Second officer to be done prior next employment.
4. A fleet-wide message to be promulgated to raise awareness amongst the
crew.

Key Message: 1. All traffic should be closely monitored visually, by RADAR / ARPA and by
all available means to determine if risk of collision exists. In any doubtful
situation about movement of traffic, officer on watch should immediately
call Master and take early action to avoid the close quarter situation.
2. Company aims at ZERO incidents. Every incident is avoidable. There are
procedures in place to help us in achieving incident free work
environment. Procedures will work if strict compliance is adhered EACH
time.

Lessons Learned 1. ARPA (CPA / TCPA) warning must be immediately acted upon and should
not be ignored. Small CPA and BCR must be considered critical and
immediate action must be taken to allow safe passing.
2. Traffic situation should not be taken for granted that it would clear by itself,
especially for fishing vessels. Compliance to “International Regulation for
Prevention of Collision at Sea” and company SMS procedures must
always be ensured.
3. When encountering fishing traffic, following factors must be considered,
but not limited to:
- Bridge of fishing vessels may not be manned
- They may move quickly or unpredictably
- They might not exhibit the correct navigation lights and signals
- Non-availability of navigational and communication equipment on
fishing vessels
- Use vessel’s whistle and/or signalling lamp to attract attention when
needed.

Team All masters are required to conduct an extra ordinary Bridge Team
engagement / Meeting and discuss key message and lessons learned with the
discussion topics shipboard team. Also discuss below topics:

1. How could we have prevented this incident? Do we know relevant

navigation procedures for navigating in coastal waters as per company
SMS?
2. Are all deck officers aware of their responsibilities as per “International
Regulation for Prevention of Collision at Sea” 1972, as amended?
3. Do we have similar situations on board where Master is not being called in
doubtful situations of targets are not passing at safe distance off?
4. What are the reasons officers ignore the safety alarm on critical navigation
equipment? Do officers know the consequences of ignoring alarm?
5. How can another team member, such as duty AB, assist in this situation to
enhance judgment process and decision making?
6. How is the positive Challenge and Response environment your ship?