Proceedings magazine is a communication tool for the Coast Guard's Marine Safety & Security Council. Each quarterly magazine focuses on a specific theme of interest to the marine industry.
Issue link: http://uscgproceedings.epubxp.com/i/665311
49 Spring 2016 Proceedings www.uscg.mil/proceedings The SMS in place on board the Delta Mariner addressed the company's expectation for bridge team manage- ment, including maintaining a focused watch, the open exchange of information, the prevention of distraction, and the creation of a team environment. The practice of good seamanship was to be observed at all times on watch, and each individual on watch was required to be alert and attentive to their respective duties relevant to the safety of the vessel. The master and DWOs 5 were instructed to always 'remain alert to the pilot's or mooring master's handling of the vessel and be prepared to intervene when necessary to safeguard personnel, environment, vessel, or cargo.' The NTSB report further refers to a sequence of events that began as the ship approached the Eggner's Ferry Bridge: … when the C/M 6 received his first instruction from the pilot to steer towards the green light of the 'E' span, through the time of the vessel's allision with the EFB, 7 none of the crewmembers present upon the vessel's navi- gation bridge countermanded or challenged the pilot's instruction to steer toward the green light marking the center of the 'E' span. As the vessel continued on its course, no attempt was made by the pilot, or the crewmembers to obtain a fx upon the vessel's position using other than visual means with the vessel's two spotlights. Per the SMS, the responsibility for obtaining vessel position fxes was the responsi bility of the DWO who was not on the helm position, in this case, the 3/M. 8 The SMS stated, 'the helmsman shall have no other duties when assigned to the helm,' and 'when the deck watch offcer is acting as helmsman, a second deck offcer and, or the master will be on the bridge to perform all other navigation and watch duties.' Ultimately, the ship struck the lighted recreational span of the Eggner's Ferry Bridge on the east side of Kentucky Lake. According to the National Transportation Safety Board (NTSB) report: The investigation revealed that the Delta Mariner's safety management system, developed by the company more than 10 years earlier and in place at the time of the accident, was not effectively implemented. Overall, [the company] provided ineffective oversight of the Delta Mariner's operations. Due to the vessel's good safety record and the company's reliance on proactive safety measures and a crew of well- trained, experienced deep-sea mariners to provide a high level of safety, the company became complacent regarding the safety of the vessel's operations. The investigation also found the expertise required of con- tract pilots was not clearly defned, and contract pilots and the Delta Mariner's deck offcers lacked clear under- standing of the guidance expected from contract pilots while serving on the bridge of a vessel. In addition, the safety management system discussed a passage plan, which is used to plan a voyage and take into account all diffculties the vessel expects to face along the transit. The passage plan was also supposed to detail the strategies proposed to mitigate any risks encountered. The NTSB report noted: [The company's] safety management system documents stated, 'A passage plan is of no value unless it is utilized by all team members — including the pilot.' Investigators found no evidence, however, that the passage plan was reviewed by deck watch offcers during the voyage. The National Transportation Safety Board report also noted: As the vessel approached Eggner's Ferry Bridge, the bridge team and contract pilot of the Delta Mariner were largely unaware of what lighting should have been visible on the bridge and which span allowed suffcient clearance for safe passage. The contract pilot and bridge team focused exclusively on the few lights visible on the bridge while ignoring readily available electronic charting system displays, which could have provided critical information about the vessel's posi- tion in relation to the bridge and the bridge's correct light- ing scheme. Despite this lack of information, the contract pilot continued to direct the vessel toward a span that was too low for the Delta Mariner. Further, despite the contract pilot's apparent uncertainty, none of the bridge team challenged his directions. Screen capture from a cell phone video taken by a mate aboard the M/ V Aiviq shows the tow wire on the right leading to the MODU Kulluk under tow. The computer screen on the left shows the readout in tons on the towing hawser (boxed in yellow) as 227 metric tons. The vessel's crew failed to recognize the importance of this critical measurement. U.S. Coast Guard image.