This document discusses human factors that contribute to navigational errors, including fatigue, stress, commercial pressures, and distractions on the bridge. It analyzes several case studies of shipping accidents and concludes that the root causes often involve operational issues like fatigue from excessive work hours, stresses of ship operations, and pressures to adhere to schedules that incentivize risky behavior. Addressing these systemic human factors through policy changes could help reduce navigational accidents.

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9th December 2012
Capt Ashok Menon

2. Safe Navigation
► Safer Ships
- safety of the ship and lives
►Protection of environment
► Protection of Property
►Commercial
- Financial Loss
- Loss of Time

5. ► Human error often touted as the
culprit for 75% of navigational
errors.
► Reasons are many:
- Negligence / Ignorance
- Misinterpretation of ROR
- Wrong judgement
- Personal factors

6. ► Root Cause analysis
Most important of these root
causes – Operational exigencies
such as:
- Fatigue and stress
- Commercial pressures
- Fear of missing ETA, Tide, Pilots,
etc.
- VTMS errors

7. Fatigue and Stress
► STCW requires rest hours of at
least 77 hours per week and 10 hrs
per day, of which 6 hrs must be
continuous.
►This is a difficult task with the
existing manning level, especially in
ports. Forces ships personnel to
work in excess of the rest hours
requirement.

8. ►THE EFFECT OF STRESS!!!

9. ► EFFECT OF SHIP OPERATIONS
►We often neglect the effect that
continuous ship operations have on
the decision making and
judgmental capabilities of the
watchkeeping Officer and Master.
►The pressures of day-to-day
operations has been found to be
the root cause behind many
navigational accidents.

10. ► Commercial Pressures
-- Various types of pressures are
exerted on the Master, forcing him
to take short cuts, unsafe actions
and wrong decisions
- Such pressures include loading to a
draft deemed unsafe for the
destination port, trying to take
short cuts in order to save fuel etc.

11. ► Over-speeding to maintain time.
- Ships need to maintain ETAs, due
to pilot timings, tidal restrictions,
maintaining vessel schedules, etc.
- Thus Masters are tempted not to
reduce the ships speed even in
situations where such reduction is
required for navigational safety.
►Leads to collisions, close quarter
situations groundings due to squat

12. ► Distractions on the bridge
- Paperwork
- Idle Gossip
- VHF Communication / Satellite Calls
- Chart corrections

13. ► Reduction of watch levels
- Adequate watch levels not maintd
due to crew on other jobs
- Chief Officer busy with hold
cleaning etc, watchkeepers keeping
six-on and six off watch causing
fatigue
- Only Watchkeeping Officer on
bridge in daytime (allowed under
SOLAS) not for all situations.

14.  CASE STUDIES

15.  Collision Between the Car Carrier
Baltic Ace and the Container ship
Corvus J off Netherlands coast in
the freezing waters of the North
Sea on 6th Dec 2012

16.  The bahamian-flagged Baltic Ace
was headed to Finland, from
Zeebrugge, when it collided about 40
miles off the coast of the netherlands
with Cyprus-flagged Corvus j, which
was on its way to Antwerp

17.  CASE STUDIES

19. The Baltic ace which was hit on her
port side was split open.
She started to take in water and soon
capsized.
Six of her crew died and a further
seven are missing, presumably dea
in the icy waters.

21. ►The Baltic Ace had the Corvus J on her
own port side, while the Corvus J had
the Baltic Ace fine on her starboard
bow.
►Thus it appears that the Corvus J was
the give way vessel while the Baltic Ace
was the stand on vessel.

23. ►MSC Chitra – Khalijia 3
7th August, 2010 - off Mumbai port
- MSC Chitra collided with Khalijia 3.
- MSC Chitra subsequently capsized,
causing huge environmental
pollution
- Many containers had IMDG cargo
which caused unknown damage to
the ecology of the Indian coastline.

24. ►The investigation launched by DG:
► Master of Khalijia 3 was under a
long term fatigue and was stressed
due to the vessel having been
grounded for several days prior to
entering Mumbai port - decision
making
- Master did not reduce speed in
order to pick up the pilot as well as
not to miss the tide.

25. ► Master of MSC Chitra guilty of
human error in not following ROR.
►Although he was the stand-on
vessel, he was not relieved of his
obligation to keep clear.
►Was traveling at full speed.
►Did not take cognizance of erratic
manoeuvre by Khalijis 3
►Both Masters certificates
suspended.

27. MV RENA GROUNDING
►236-metre
(774 ft) Panamax container ship
►Grounded on Astrolabe Reef, off
New Zealand, a charted and
prominent reef at 2.20am on May
5, 2011 whilst doing over 17 knots.
►Ship broke into two causing much
pollution.

28. ► The investigation it was revealed
that the root cause of this disaster
was the Master’s decision to take a
short cut in order to arrive in time
and maintain his ETA.
►Charged with negligence and found
guilty.
►Probably commercial pressures
forced him to take the shortcut.

31. M.V. PRATIBHA CAUVERY
►On October 31st, 2012, the tanker
Pratibha Cauvery drifted from her
anchorage under the influence of
the cyclone Neelam and grounded
off Elliot’s Beach in Chennai.
► Vessel had very less fuel,
practically in un-pumpable range,
hence could not manoeuvre.

32.  MT Pratibha Cauvery was not sea-
worthy since October 2 and had
been berthed at the Chennai Port
since a month.
 There was no supply of fuel and
provisions to the ship since then.
 The Port asked the ship to vacate
the anchorage before the onset of
the storm but she could not do so.

33. Thus Master was blamed for not
leaving the port as required and
hence causing the ship to drift and
ground.

36. Majestic Bulker COLLISION
►The Majestic Bulker, a Panamax
Bulk Carrier collided with another
bulk carrier in good visibility and
open waters, at full speed.
► Both ships were declared total
constructive loss and both Masters
charged with negligence.
►There was no loss of life, but
pollution occurred.

38. ►The vessel which was supposed to
give way was cleaning her cargo
holds prior to loading grain at a U.
S port. Thus the two young officers
were alternating watches.
►Keeping six hours continuous
watch can be very difficult and the
second officer sat on the pilot chair
and promptly went to sleep at five
in the morning till the collision.

39. ►Thus we see that there are many other
operational reasons for navigational
incidents which need to be looked into
and preventive actions taken to have a
repetition of these.

40. ►THANK YOU