SUNDAY LONG READ – No 25
I haven’t shared a Sunday Long Read for a while, so let’s get back into it with a doozy… the grounding of BBC MARMARA off Scotland in July 2021.
There’s a lot to unpack in this incident: departures from best practice, minimal crewing levels, power gradients, command and control, biases, normalisation of deviance, drift… the list is endless. So, what happened?
The summary is simple. BBC MARMARA was sailing through a narrow strait off the north-west coast of Scotland. It was during the night 12-4 watch, and the officer of the watch was the only person on the bridge. The OOW had consumed alcohol before taking over the watch, and while on watch. The OOW fell asleep and the ship grounded.
The MAIB report reflects the usual high standard of investigation we expect from this organisation. Safety issues shown in the report included:
· The OOW was asleep when the vessel grounded.
· There was a failure of the safety barriers that may have roused the OOW from their sleep; including the presence of a look-out, use of the BNWAS, and intervention by the Coastguard.
· Maintenance of the vessel was prioritised over safe watchkeeping practices.
· Records and documentation were falsified to avoid adverse findings during audits and inspections.
I’m not going to consider the role of the Vessel Traffic Monitoring service provided by the Coastguard. It’s not an area where I have specific expertise.
What stands out to me is the culture on board the vessel. In an ideal world, there is no misuse of alcohol, personnel are well-rested and alert, and best practice is adhered to. In the rare event of a deviation from best practice, it is openly reported and considered, with learnings implemented to improve future practice.
But what we see in the pages of the MAIB report is the opposite. We see maintenance of the vessel prioritised over proper nighttime look-out duties, we see the Master keeping a navigation watch while fulfilling all their other duties, we see a crew who find solace in the misuse of alcohol, and record-keeping intended to deceive.
Given the deviance from best practice, it’s easy to point the finger at the personnel on the vessel. But these behaviours did not develop overnight. Falsification of record-keeping, and misuse of alcohol are emergent issues, not primary causes. They are indicators of a deeper problem, not the problem itself.
I encourage you to read the report and share this post with your colleagues. Please feel free to leave comments, below.
#safety #casualty #accident #incident #maritime #investigation #navigation #crew #fatigue #culture #management #ism #sms
Link to official MAIB investigation report:
https://lnkd.in/g2UPjaXz
