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Bridge resources management lrg

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Bridge resources management lrg

  1. 1. Grunt Productions 2009 BRIDGE RESOURCESBRIDGE RESOURCES MANAGEMENTMANAGEMENT A Brief By Lance GrindleyA Brief By Lance Grindley
  2. 2. Grunt Productions 2009 Royal MajestyRoyal Majesty
  3. 3. Grunt Productions 2009 Royal MajestyRoyal Majesty After the ship sailed from Bermuda, someone had stepped onAfter 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 hadNone of the officers on watch noticed that the GPS had reverted to Dead Reckoning Mode, and diligently plottedreverted 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 buoysOn arrival off Nantucket, the vessel passed navigation buoys which were not on the course line, missed navigationwhich were not on the course line, missed navigation buoys which were on the course, spotted lighthouses thatbuoys which were on the course, spotted lighthouses that they shouldn’t have seen, and were sailing in depths ofthey shouldn’t have seen, and were sailing in depths of water that did not match the chart.water that did not match the chart.
  4. 4. Grunt Productions 2009 Royal MajestyRoyal Majesty
  5. 5. Grunt Productions 2009 Royal MajestyRoyal Majesty About 2225 on June 10, 1995, the passenger shipAbout 2225 on June 10, 1995, the passenger ship Royal MajestyRoyal Majesty grounded on Rose and Crown Shoal about 10 miles east ofgrounded on Rose and Crown Shoal about 10 miles east of Nantucket Island, Massachusetts. The vessel, with 1,509Nantucket Island, Massachusetts. The vessel, with 1,509 persons on board, was en route from St. George’s, Bermuda, topersons on board, was en route from St. George’s, Bermuda, to Boston, Massachusetts. At the time of grounding she was 17Boston, 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 badInitial 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.
  6. 6. Grunt Productions 2009 Royal MajestyRoyal Majesty The cause of the grounding of theThe cause of the grounding of the Royal MajestyRoyal Majesty was thewas the watch officers’ over-reliance on the automated features ofwatch officers’ over-reliance on the automated features of the integrated bridge system, Majesty Cruise Line’s failurethe integrated bridge system, Majesty Cruise Line’s failure to ensure that its officers were adequately trained in theto ensure that its officers were adequately trained in the automated features of the integrated bridge system and inautomated features of the integrated bridge system and in the implications of this automation for bridge resourcethe implications of this automation for bridge resource management, the deficiencies in the design andmanagement, the deficiencies in the design and implementation of the integrated bridge system and in theimplementation of the integrated bridge system and in the procedures for its operation, and the second officer’sprocedures for its operation, and the second officer’s failure to take corrective action after several cues indicatedfailure to take corrective action after several cues indicated the vessel was off course.the vessel was off course.
  7. 7. Grunt Productions 2009 Royal MajestyRoyal Majesty Contributing factors were the inadequacy of international trainingContributing factors were the inadequacy of international training standards for watchkeepers aboard vessels equipped withstandards for watchkeepers aboard vessels equipped with electronic navigation systems and integrated bridge systemselectronic 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 aboardinstallation, and testing of integrated bridge systems aboard vessels.vessels.
  8. 8. Grunt Productions 2009 Important RequirementsImportant Requirements How does Bridge Resources Management affect the Vessels Operating for Gulf Offshore N.S. Ltd ?
  9. 9. Grunt Productions 2009 OopsOops
  10. 10. Grunt Productions 2009 Important RequirementsImportant Requirements  As on any vessel, certain design features andAs on any vessel, certain design features and personnel issues can affect the safe navigation andpersonnel 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
  11. 11. Grunt Productions 2009 Wheelhouse LayoutWheelhouse Layout  Good design makes working easier.Good design makes working easier.  Equipment, instrumentation, consoles, walkways andEquipment, instrumentation, consoles, walkways and seating must be correctly arranged.seating must be correctly arranged.  The view to the outside is to be maximised and notThe view to the outside is to be maximised and not blocked by electronic devices.blocked by electronic devices.
  12. 12. Grunt Productions 2009 Wheelhouse LayoutWheelhouse Layout What is wrong here? The radars etc. obstruct the view thereby detracting from keeping a good lookout and also reducing situational awareness
  13. 13. Grunt Productions 2009 Wheelhouse LayoutWheelhouse Layout Good bridge design ?
  14. 14. Grunt Productions 2009 Wheelhouse LayoutWheelhouse Layout  AlarmsAlarms In order to prevent distraction by, and unnecessaryIn 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 positionCentralise alarms to one position
  15. 15. Grunt Productions 2009 Wheelhouse LayoutWheelhouse Layout  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
  16. 16. Grunt Productions 2009 Wheelhouse LayoutWheelhouse Layout Main Alarm Panel
  17. 17. Grunt Productions 2009 Wheelhouse LayoutWheelhouse Layout  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 ofElectronic screens interfeering with view out of windowswindows
  18. 18. Grunt Productions 2009 ““Where did that come From?“Where did that come From?“
  19. 19. Grunt Productions 2009 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
  20. 20. Grunt Productions 2009 Crew Specific MeasuresCrew Specific Measures  All persons manning the bridge should be mentallyAll 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 anWhilst routine work allows little of this, in an incident where the risk is greater, and / or a rapidlyincident where the risk is greater, and / or a rapidly changing position can drastically increase that need.changing position can drastically increase that need.
  21. 21. Grunt Productions 2009 Crew Specific MeasuresCrew Specific Measures  Important PointsImportant Points 1. Experienced and trained team1. Experienced and trained team 2. Dangers and risks established2. Dangers and risks established 3. Clear communication3. Clear communication 4. Good decision making4. Good decision making 5. Leadership5. Leadership 6. Passage planning6. Passage planning 7. Situationally aware7. Situationally aware
  22. 22. Grunt Productions 2009 Error ChainsError Chains
  23. 23. Grunt Productions 2009 Error ChainsError Chains  Incidents are always a product of a number of adverseIncidents are always a product of a number of adverse circumstances, the corrective action of which wouldcircumstances, 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.
  24. 24. Grunt Productions 2009 Error ChainsError Chains  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
  25. 25. Grunt Productions 2009 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.
  26. 26. Grunt Productions 2009 Error ChainsError Chains  Distraction - The full attention of a team member on one eventDistraction - 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.
  27. 27. Grunt Productions 2009 Error ChainsError Chains  Inadequacy or Confusion - A feeling of loss of control of theInadequacy or Confusion - A feeling of loss of control of the situationsituation
  28. 28. Grunt Productions 2009 Error ChainsError Chains  Communication Breakdown - this can be caused by excessiveCommunication Breakdown - this can be caused by excessive background noise, lack of common language or differingbackground noise, lack of common language or differing procedural methods.procedural methods.
  29. 29. Grunt Productions 2009 Error ChainsError Chains  Improper Conn or Lookout - this may be as a result of a lackImproper Conn or Lookout - this may be as a result of a lack of situational awareness.of situational awareness.
  30. 30. Grunt Productions 2009 Error ChainsError Chains  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 andProcedural violation - Unjustified departure from clearly defined and understood operating procedures must be recognised as a breakdown ofunderstood operating procedures must be recognised as a breakdown of situational awareness, e.g. proceding the wrong way in a traffic separationsituational awareness, e.g. proceding the wrong way in a traffic separation schemescheme
  31. 31. Grunt Productions 2009 Error ChainsError Chains
  32. 32. Grunt Productions 2009 Casualties and their CausesCasualties and their Causes 1. Having insufficient personnel.1. Having insufficient personnel. 2. Insufficient communication to / from the2. 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 restricted4. Insufficient or non-reduction of speed in restricted visibility.visibility.
  33. 33. Grunt Productions 2009 Casualties and their CausesCasualties and their Causes  Causes of GroundingsCauses of Groundings 1. 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.
  34. 34. Grunt Productions 2009 Casualties and their CausesCasualties and their Causes  Causes of Groundings (Continued)Causes of Groundings (Continued) 6. Failure to use or monitor echo sounder when in6. 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 are8. Failure to ensure important navigational decisions are independently checked by another crew member.independently checked by another crew member.
  35. 35. Grunt Productions 2009
  36. 36. Grunt Productions 2009 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.
  37. 37. Grunt Productions 2009 Master / Crew CommunicationMaster / Crew Communication  The Master and crew must work together to ensure the safe navigation ofThe 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 theCrew 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.
  38. 38. Grunt Productions 2009 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.
  39. 39. Grunt Productions 2009 Communication on BoardCommunication on Board There must be a clear chain of commandThere must be a clear chain of command MasterMaster OOWOOW LookoutLookout
  40. 40. Grunt Productions 2009 Wheelhouse CommunicationWheelhouse Communication • The chain of command must still allow positiveThe chain of command must still allow positive involvement by all members of the team, allowinginvolvement by all members of the team, allowing them to speak out especially when if there is anythem to speak out especially when if there is any doubt.doubt. • Communication must be calm, clear andCommunication must be calm, clear and respectful.respectful. • Good feedback between the team is also important.Good feedback between the team is also important.
  41. 41. Grunt Productions 2009
  42. 42. Grunt Productions 2009 Planning for EmergenciesPlanning for Emergencies  DrillDrill – PracticePractice – ObserveObserve – DiscussDiscuss  EmergencyEmergency – STEP Scenario, Test, Evaluate, PlanSTEP Scenario, Test, Evaluate, Plan
  43. 43. Grunt Productions 2009 S.T.E.P.S.T.E.P. - Action- Action SS Create aCreate a SScenariocenario TT TTest the response for conflictest the response for conflict EE EEvaluate the resultsvaluate the results PP Develop ContingencyDevelop Contingency PPlanslans
  44. 44. Grunt Productions 2009 COLLISION INITIAL ACTION 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 ASSISTANCE EXCHANGE 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
  45. 45. Grunt Productions 2009 Emergencies - BriefingEmergencies - Briefing The Master must:The Master must: • use clear and precise commandsuse clear and precise commands • use standard marine vocabulary and unambiguous phrasesuse standard marine vocabulary and unambiguous phrases • display an understanding of the situationdisplay an understanding of the situation • display confidence and calmnessdisplay confidence and calmness • enforce use chain of commandenforce use chain of command
  46. 46. Grunt Productions 2009 Communication in EmergenciesCommunication in Emergencies  Communication aids such as telephone and radios properlyCommunication 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.
  47. 47. Grunt Productions 2009 SummarySummary  Bridge Resources Management promotes good teamworkBridge Resources Management promotes good teamwork on board. It is primarily based upon clear and conciseon board. It is primarily based upon clear and concise communication between all members of the team in anycommunication 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 errorIf the team is working together and looking for error chains developing, then steps can be taken to break thatchains developing, then steps can be taken to break that chain and prevent an incident.chain and prevent an incident.
  48. 48. Grunt Productions 2009 SummarySummary  Experience and training are an important part of BridgeExperience and training are an important part of Bridge Resources Management.Resources Management.  Bridge Resources Management is also assisted by goodBridge Resources Management is also assisted by good structural design, minimisation of unnecessarystructural design, minimisation of unnecessary distractions such as alarms, back scatter of lights, etc,.distractions such as alarms, back scatter of lights, etc,.
  49. 49. Grunt Productions 2009 The General Idea is to stop this HappeningThe General Idea is to stop this Happening

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