Bridge resources management lrg

Grunt Productions 2009

BRIDGE RESOURCES BRIDGE RESOURCES MANAGEMENTMANAGEMENT

A Brief By Lance GrindleyA Brief By Lance Grindley


Royal MajestyRoyal Majesty



After the ship sailed from Bermuda, someone had stepped on After the ship sailed from Bermuda, someone had stepped on the aerial cable of the GPS, 34 hours before the grounding.the aerial cable of the GPS, 34 hours before the grounding.

None of the officers on watch noticed that the GPS had None of the officers on watch noticed that the GPS had reverted to Dead Reckoning Mode, and diligently plotted reverted to Dead Reckoning Mode, and diligently plotted these positions on the chart. these positions on the chart.

On arrival off Nantucket, the vessel passed navigation buoys On arrival off Nantucket, the vessel passed navigation buoys which were not on the course line, missed navigation which were not on the course line, missed navigation buoys which were on the course, spotted lighthouses that buoys which were on the course, spotted lighthouses that they shouldn’t have seen, and were sailing in depths of they shouldn’t have seen, and were sailing in depths of water that did not match the chart.water that did not match the chart.



About 2225 on June 10, 1995, the passenger ship About 2225 on June 10, 1995, the passenger ship Royal Majesty Royal Majesty grounded on Rose and Crown Shoal about 10 miles east of grounded on Rose and Crown Shoal about 10 miles east of Nantucket Island, Massachusetts. The vessel, with 1,509 Nantucket Island, Massachusetts. The vessel, with 1,509 persons on board, was en route from St. George’s, Bermuda, persons on board, was en route from St. George’s, Bermuda, to Boston, Massachusetts. At the time of grounding she was 17 to Boston, Massachusetts. At the time of grounding she was 17 nautical miles off course. nautical miles off course.

Initial attempts to free the vessel were unsuccessful, due to bad Initial attempts to free the vessel were unsuccessful, due to bad weather. Rescue and refloating did occur the following day.weather. Rescue and refloating did occur the following day.


Royal MajestyRoyal MajestyThe cause of the grounding of the The cause of the grounding of the Royal Majesty Royal Majesty was the was the

watch officers’ over-reliance on the automated features of watch officers’ over-reliance on the automated features of the integrated bridge system, Majesty Cruise Line’s failure the integrated bridge system, Majesty Cruise Line’s failure to ensure that its officers were adequately trained in the to ensure that its officers were adequately trained in the automated features of the integrated bridge system and in automated features of the integrated bridge system and in the implications of this automation for bridge resource the implications of this automation for bridge resource management, the deficiencies in the design and management, the deficiencies in the design and implementation of the integrated bridge system and in the implementation of the integrated bridge system and in the procedures for its operation, and the second officer’s procedures for its operation, and the second officer’s failure to take corrective action after several cues indicated failure to take corrective action after several cues indicated the vessel was off course.the vessel was off course.



Contributing factors were the inadequacy of international training Contributing factors were the inadequacy of international training standards for watchkeepers aboard vessels equipped with standards for watchkeepers aboard vessels equipped with electronic navigation systems and integrated bridge systems electronic navigation systems and integrated bridge systems and the inadequacy of international standards for the design, and the inadequacy of international standards for the design, installation, and testing of integrated bridge systems aboard installation, and testing of integrated bridge systems aboard vessels.vessels.


Important RequirementsImportant Requirements

How does Bridge Resources Management affect the Vessels Operating for Gulf

Offshore N.S. Ltd ?


OopsOops


Important RequirementsImportant Requirements

As on any vessel, certain design features and As on any vessel, certain design features and personnel issues can affect the safe navigation and personnel issues can affect the safe navigation and operations of the vesseloperations of the vessel

1. Good design of the wheelhouse.1. Good design of the wheelhouse.

2. Good procedures.2. Good procedures.

3. Good communication practices.3. Good communication practices.

4. Good communication during emergency situations4. Good communication during emergency situations


Wheelhouse LayoutWheelhouse Layout

Good design makes working easier.Good design makes working easier. Equipment, instrumentation, consoles, walkways and Equipment, instrumentation, consoles, walkways and

seating must be correctly arranged.seating must be correctly arranged. The view to the outside is to be maximised and not The view to the outside is to be maximised and not

blocked by electronic devices.blocked by electronic devices.



What is wrong here?The radars etc. obstruct the view thereby detracting from keeping a good lookout and also reducing situational awareness



Good bridge design ?



AlarmsAlarms

In order to prevent distraction by, and unnecessary In order to prevent distraction by, and unnecessary alarms:alarms:– Minimise number of alarms by maintenanceMinimise number of alarms by maintenance– Prioritize alarms into importancePrioritize alarms into importance– Centralise alarms to one position Centralise alarms to one position



Central Alarm SystemCentral Alarm System– Gathers all alarms togetherGathers all alarms together– Colour code alarms as to their importanceColour code alarms as to their importance

Advantages:Advantages:– Reduces number of alarmsReduces number of alarms– The important alarms are immediately apparentThe important alarms are immediately apparent– No running around answering alarmsNo running around answering alarms



Main Alarm Panel



Examples of Bad DesignExamples of Bad Design– Steering position not amidshipsSteering position not amidships– Console lights harming view out at nightConsole lights harming view out at night– Confusing steering controlsConfusing steering controls– Electronic screens interfeering with view out of Electronic screens interfeering with view out of

windowswindows


““Where did that come From?“Where did that come From?“


Crew Specific MeasuresCrew Specific Measures

CommunicationCommunication 1. Bridge / Crew communication1. Bridge / Crew communication

2. Communication in the wheelhouse2. Communication in the wheelhouse

3. Planning for emergency situations3. Planning for emergency situations

4. Communication in emergency situations4. Communication in emergency situations



All persons manning the bridge should be mentally All persons manning the bridge should be mentally and physically fit, well rested, and alert.and physically fit, well rested, and alert.

Whilst routine work allows little of this, in an Whilst routine work allows little of this, in an incident where the risk is greater, and / or a rapidly incident where the risk is greater, and / or a rapidly changing position can drastically increase that need.changing position can drastically increase that need.



Important PointsImportant Points1. Experienced and trained team1. Experienced and trained team2. Dangers and risks established2. Dangers and risks established3. Clear communication3. Clear communication4. Good decision making4. Good decision making5. Leadership 5. Leadership 6. Passage planning6. Passage planning7. Situationally aware7. Situationally aware


Error ChainsError Chains



Incidents are always a product of a number of adverse Incidents are always a product of a number of adverse circumstances, the corrective action of which would circumstances, the corrective action of which would stop that incident.stop that incident.

That Corrective action is called breaking the chain.That Corrective action is called breaking the chain.



There are indicators of an error chain developing:There are indicators of an error chain developing:

1. Ambiguity1. Ambiguity

2. Distraction2. Distraction

3. Inadequacy and Confusion3. Inadequacy and Confusion

4. Communication Breakdown4. Communication Breakdown

5. Improper Con or Lookout5. Improper Con or Lookout

6. Non Compliance with Plan6. Non Compliance with Plan

7. Procedural Violation7. Procedural Violation


Error ChainsError Chains Ambiguity - Ambiguity - Navigation fixes don‘t work outNavigation fixes don‘t work out

Charted depths don‘t match the positionCharted depths don‘t match the position

Two team members do not agree on course of actionTwo team members do not agree on course of action

Team member aware procedures are not being followedTeam member aware procedures are not being followed

Junior team member feeling he cannot express a doubt.Junior team member feeling he cannot express a doubt.



Distraction - The full attention of a team member on one event Distraction - The full attention of a team member on one event to the exclusion of others or concentration on an irrelevancy, to the exclusion of others or concentration on an irrelevancy, causing loss of situational awareness.causing loss of situational awareness.



Inadequacy or Confusion - A feeling of loss of control of the Inadequacy or Confusion - A feeling of loss of control of the situationsituation



Communication Breakdown - this can be caused by excessive Communication Breakdown - this can be caused by excessive background noise, lack of common language or differing background noise, lack of common language or differing procedural methods.procedural methods.



Improper Conn or Lookout - this may be as a result of a lack Improper Conn or Lookout - this may be as a result of a lack of situational awareness.of situational awareness.



Non compliance with plan - non compliance with the passage planNon compliance with plan - non compliance with the passage plan

Procedural violation - Unjustified departure from clearly defined and Procedural violation - Unjustified departure from clearly defined and understood operating procedures must be recognised as a breakdown of understood operating procedures must be recognised as a breakdown of situational awareness, e.g. proceding the wrong way in a traffic separation situational awareness, e.g. proceding the wrong way in a traffic separation schemescheme


Casualties and their CausesCasualties and their Causes

1. Having insufficient personnel.1. Having insufficient personnel.2. Insufficient communication to / from the 2. Insufficient communication to / from the Master.Master.3. Insufficent or inattentive lookouts.3. Insufficent or inattentive lookouts.4. Insufficient or non-reduction of speed in restricted 4. Insufficient or non-reduction of speed in restricted

visibility.visibility.



Causes of GroundingsCauses of Groundings1. Failure to plan passage.1. Failure to plan passage.2. Failure to monitor track and progress.2. Failure to monitor track and progress.3. Failure to regain track after deviation.3. Failure to regain track after deviation.4. Failure to cross check fixes.4. Failure to cross check fixes.5. Failure to use visual fixes.5. Failure to use visual fixes.



Causes of Groundings (Continued)Causes of Groundings (Continued)6. Failure to use or monitor echo sounder when in 6. Failure to use or monitor echo sounder when in

restricted waters.restricted waters.7. Failure to positively identify navigation lights.7. Failure to positively identify navigation lights.8. Failure to ensure important navigational decisions are 8. Failure to ensure important navigational decisions are

independently checked by another crew member.independently checked by another crew member.


Monitoring TrackMonitoring Track

To prevent accidents:To prevent accidents:1. Radar parallel indexing.1. Radar parallel indexing.2. Appropriate fixing rate.2. Appropriate fixing rate.3. Primary and secondary fixing methods.3. Primary and secondary fixing methods.4. Allowance for set from tide and current.4. Allowance for set from tide and current.5. Use of transits/ ranges, and leading lines.5. Use of transits/ ranges, and leading lines.6. Use of clearing marks and head marks.6. Use of clearing marks and head marks.


Master / Crew CommunicationMaster / Crew Communication

The Master and crew must work together to ensure the safe navigation of The Master and crew must work together to ensure the safe navigation of the vesssel.the vesssel.

Crew must monitor the Master‘s actions, and in case of doubt, question the Crew must monitor the Master‘s actions, and in case of doubt, question the Master, and if necessary take corrective action.Master, and if necessary take corrective action.

If in doubt, use Stop, Assess, Plan.If in doubt, use Stop, Assess, Plan.


Master / Crew CommunicationMaster / Crew Communication

Problems can arise because of:Problems can arise because of:

1. Dominating personality of Master.1. Dominating personality of Master.

2. Malicious obedience.2. Malicious obedience.

3. Lack of monitoring of orders.3. Lack of monitoring of orders.

4. Lack of briefing by Master.4. Lack of briefing by Master.

5. Use of non standard orders.5. Use of non standard orders.

6. Lack of teamwork.6. Lack of teamwork.


Communication on BoardCommunication on Board

There must be a clear chain of commandThere must be a clear chain of command

Master Master

OOW OOW Lookout Lookout


Wheelhouse CommunicationWheelhouse Communication

• The chain of command must still allow positive The chain of command must still allow positive involvement by all members of the team, allowing involvement by all members of the team, allowing them to speak out especially when if there is any them to speak out especially when if there is any doubt.doubt.

• Communication must be calm, clear and Communication must be calm, clear and respectful.respectful.

• Good feedback between the team is also important.Good feedback between the team is also important.


Planning for EmergenciesPlanning for Emergencies

DrillDrill– PracticePractice– ObserveObserve– DiscussDiscuss

EmergencyEmergency– STEP Scenario, Test, Evaluate, PlanSTEP Scenario, Test, Evaluate, Plan


S.T.E.P.S.T.E.P. - Action - Action

SS Create a Create a SScenario cenario

TT TTest the response for conflictest the response for conflict

EE EEvaluate the results valuate the results

PP Develop Contingency Develop Contingency PPlanslans


COLLISION

INITIALACTION

BRIDGE TEAM

EMERGENCY TEAM

SOUND GENERAL ALARM

MANOEUVRE VESSEL TO MINIMISE EFFECTS

MUSTER CREW

WATERTIGHT DOORS

STOP MAIN ENGINES

DECK LIGHTING

START FIRE PUMP

MONITOR WEATHER CONDITIONS

INITIALISE SOPEP IF REQUIRED

DISPLAY CORRECT LIGHTS

ADDITIONAL RISK FROM FIRE / EXPLOSION

OFFER ASSISTANCEEXCHANGE PARTICULARS

STABILITY ASSESSMENT

CONTINGENCY PLAN

PLOT POSITION & SAFE PORT OPTIONS

COMMUNICATIONS

VHF TO CHANNEL 16 & 13 AS REQUIRED

UPDATE GMDSS WITH POSITION

BROADCAST DISTRESS ALERT AND MESSAGE

INFORM D.P.A.

INFORM MAIB

CHECK FOR FIRE, DAMAGE, AND POLLUTION

SOUND BILGES AND TANKS

ESTIMATE DAMAGED AREA AND ESTABLISH IF ABOVE OR

BELOW W/L

CHECK FOR CASUALTIES OR MISSING PERSONS

ASSESS IF REPAIRS ARE POSSIBLE

CALL THE MASTER

ACTION TO BE TAKEN IN THE EVENT OF A COLLISION


Emergencies - BriefingEmergencies - Briefing

The Master must:The Master must:

• use clear and precise commands use clear and precise commands

• use standard marine vocabulary and unambiguous phrasesuse standard marine vocabulary and unambiguous phrases

• display an understanding of the situation display an understanding of the situation

• display confidence and calmnessdisplay confidence and calmness

• enforce use chain of commandenforce use chain of command


Communication in EmergenciesCommunication in Emergencies

Communication aids such as telephone and radios properly Communication aids such as telephone and radios properly evaluated and in working order.evaluated and in working order.

Use of standard marine vocabulary.Use of standard marine vocabulary. Use of standard commands.Use of standard commands. Clear and unambiguous commands.Clear and unambiguous commands. Commands properly acknowledged.Commands properly acknowledged. Commands correctly and expeditiously carried out.Commands correctly and expeditiously carried out.


SummarySummary

Bridge Resources Management promotes good teamwork Bridge Resources Management promotes good teamwork on board. It is primarily based upon clear and concise on board. It is primarily based upon clear and concise communication between all members of the team in any communication between all members of the team in any situation, and the promotion of feedback to the Master.situation, and the promotion of feedback to the Master.

If the team is working together and looking for error If the team is working together and looking for error chains developing, then steps can be taken to break that chains developing, then steps can be taken to break that chain and prevent an incident.chain and prevent an incident.


SummarySummary

Experience and training are an important part of Bridge Experience and training are an important part of Bridge Resources Management.Resources Management.

Bridge Resources Management is also assisted by good Bridge Resources Management is also assisted by good structural design, minimisation of unnecessary structural design, minimisation of unnecessary distractions such as alarms, back scatter of lights, etc,.distractions such as alarms, back scatter of lights, etc,.


The General Idea is to stop this HappeningThe General Idea is to stop this Happening

Bridge resources management lrg

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