LESSONS LEARNED FROM INCIDENT INVESTIGATION

ID:AS/025/2019 Grounding and Breach of hull

Incident Description At around 0348 LT, while vessel was transiting the Suez Canal Southbound through
(What happened): the “Al Ballah Bypass West Branch” under pilotage, the vessel experienced bow
cushion/ bank suction effect. Due to the bank effects, the vessel’s bow swung
uncontrollably and momentarily ran aground on the port side but then continued the
transit. During this period, the Master had gone down to his cabin to freshen up 15
minutes prior the incident and was summoned by the OOW just before the grounding.

At about 0530 LT, the vessel experienced a list of 1 degree to the port side. While
investigating the cause of the list, it was noted that the vessel had breached 1P
double bottom water ballast tank.

The vessel anchored on completing the transit to carry out repairs. Temporary repairs
by welding the breach from outside were done, and the vessel sailed for the
discharge port.

Photos:

Potential Outcome
(What else could Foundering and Pollution
have gone wrong):
Immediate Causes: Incorrect Navigation or Ship Handling.

The combination of the late alteration of course with bank effect and hard over
helm to port caused the loss of control.

“While maintaining the course of 164T, the vessel was required to alter to port to her
next course of 154T upon arriving at the waypoint 14; however, as she was to the
east of planned track, the pilot continued on course of 164T. At 034543LT the pilot
ordered heading to 160T to steer and immediately ordered Port 20 rudder. At this
time the vessel was already past her planned route track of 154T, and the bow was

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 LESSONS LEARNED FROM INCIDENT INVESTIGATION

closing the starboard side canal bank. At 034555LT the vessel started swinging to
port side. At 034605LT the pilot ordered hard to port with heading 158.2T. At
034612LT the vessel started swinging rapidly to port side, which was enhanced by
Bow Cushion effect. Instead of giving immediate Hard to Starboard order to helm at
this time to withstand Bow Cushion effect the Pilot hesitated till 34628 LT when he
ordered just Mid ship followed by Hard to Starboard at 034634LT on heading 142.1T.”

Root / Basic Causes:
1. Bridge Manning Level: The Master was on the bridge from the past 7 hours and
went down to take a short break without being properly relieved.
2. Inadequate Challenge by OOW: The OOW did not challenge the pilot on
delayed alteration and ship handling directly though he called the master on the
bridge immediately.

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 LESSONS LEARNED FROM INCIDENT INVESTIGATION

Corrective/Preventive Action
Measures: 1. The bridge manning levels must be maintained at all times.
2. The culture of challenge and response should be promoted in the bridge
team.
Key Message: Pilot actions should be monitored at all stages. The Master and the ship’s officers
continue to remain responsible for the safe navigation of the vessel even in the
presence of a pilot
Lessons Learned: “Bow cushion and Bank suction effect” to be discussed in bridge team meetings.
Pilot actions in areas known for past groundings and pilot errors should be monitored
with an eagle eye.
In your opinion, what could have averted the incident?
Team engagement / What are the different forces that act on the vessel?
discussion topics What is “Bow cushion and Bank suction” effects on the vessel?
How do we promote the culture of challenge and response?

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