Bridge resources management lrg

Grunt Productions 2009
BRIDGE RESOURCESBRIDGE RESOURCES
MANAGEMENTMANAGEMENT
A Brief By Lance GrindleyA Brief By Lance Grindley

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.

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.

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.

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.

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 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

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.

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 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

 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 ofElectronic 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 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.

 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

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.

 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

 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 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.

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

 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.

 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.

 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

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.

 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.

 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.

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 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.

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
MasterMaster
OOWOOW LookoutLookout

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.

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 aCreate a SScenariocenario
TT TTest the response for conflictest the response for conflict
EE EEvaluate the resultsvaluate the results
PP Develop ContingencyDevelop Contingency PPlanslans

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

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

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.

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.

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,.

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

Bridge resources management lrg

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