An investigation by the Marine Accident Investigation Branch (MAIB) into the collision of the Red Falcon ferry into a moored yacht in Cowes Harbour on 21st October 2018 has concluded.
The report reveals that Red Falcon – with a gross tonnage of 4,128 – collided with the yacht, Greylag, after the master became disorientated in the fog and inadvertently drove the ferry in the wrong direction. The yacht was a total loss, but no members of the crew or public were injured.
Lack of practice using just the instruments
Investigators say the helmsman experienced difficulty steering the vessel into Cowes Harbour and was insufficiently practised at steering by using the just digital compass.
The master took over, operating the steering and propulsion himself, but had to rely completely on the instruments. His lack of practice at using just the instruments led to him over-correcting the steering, resulting in the ferry swinging out of the channel.
Master experienced “cognitive overload”
The report states:
“He [the master] became disorientated because he was suffering from cognitive overload due to high stress, lack of visibility, bridge equipment ergonomics, and the breakdown of support from the bridge team.
“The master’s actions and the lack of communication of his intent, resulted in the members of the bridge team becoming disengaged, and this led to an absence of any challenge to the master’s decisions.”
Full details in the report below.
Actions taken
Red Funnel has since taken steps to improve its management processes, equipment and training routines, and Cowes Harbour Commission has undertaken a review of its aids to navigation and risk assessments
Among other things, Red Funnel has implemented a new navigation procedure, amended its blind pilotage routine, reviewed its resource management training programme, have started regular navigation assessments of vessel operations, changed the position of the radar units.
Recommendations
Red Funnel has been recommended to:
- Conduct regular assessment of ship-handling capabilities of masters and C/Os, not limited solely to normal operational routines of berthing and unberthing, including pilotage by instruments alone.
- Review the method of determining the orientation of the vessel displayed on the ship’s electronic chart system, to ensure that the system is not solely reliant on the operation of a toggle switch, and that there is a method of positive confirmation of the orientation displayed at each manoeuvring console
The report
Full details can be found in the report below – embedded for your convenience (click on full screen icon to see larger version)
