“Fatigue and high mental loading” were cited as contributing to the collision between the Huayang Endeavour bulk carrier and Seafrontier oil tanker in the Dover Strait on July 1st 2017, according to the Marine Accident Investigation Branch (MAIB) report. The two Hong Kong registered vessels collided at 3.04 am during an overtaking manoeuvre. Despite damage they able to proceed to nearby ports for damage assessments.
Incident Investigation
Poor Situation Awareness (SA) and fatigue were cited as the key contributing factors to the incident. Issues in relation to communication and shared situation awareness between the bridge crews were also identified. The Very High Frequency (VHF) radio conversation between the two vessels had resulted in the two bridge teams holding conflicting views as to what had been agreed regarding Huayang Endeavour overtaking Seafrontier. Subsequently, Seafrontier’s bridge team did not check for sea room astern before altering course, leading to a close quarter situation between the two vessels. The misunderstanding and confusion is apparent in the exert below (MAIB, p5).
In addition, the report identified that the Seafrontier’s master had been present on the bridge for over 14 hours, at his maximum permitted working hours, and was likely suffering from fatigue. This would have a negative impact on his ability to monitor the ship positions during a complex task, and subsequent decision making.
What is Situation Awareness?
Situation Awareness (SA) refers to the ability to know what is going on around you and use that information to predict how the situation may develop (Endsley, 1995). Consequently, SA is the foundation of good decision making and a fundamental Non-Technical Skill (NTS; see previous articles) required for safe and efficient performance. With the introduction of increasingly complex technology, the recognition of SA has spread across high risk industries from aviation, rail, nuclear power and more recently healthcare as well as in shipping (see Roberts et al., 2015). SA is typically training in the context of crew resource management.
What is Crew Resource Management?
Crew Resource Management (CRM) originated in the 1970’s with NASA as a way of improving flight crews teamwork, SA, decision making and leadership (Kanki, 2010). Non-technical skills are cognitive (situation awareness and decision making), social (teamwork, leadership, communication) and personal resource (coping with stress and fatigue) skills that complement technical skills and contribute to safe and efficient performance (Flin et al. 2003). Training these skills is referred to as Crew Resource Management. These are essentially the skills that all good operators use in their daily work to achieve consistently high performance.
CRM training typically covers the key non-technical skills through various teaching methods including time in the classroom and practising these skills in a simulator. In particular, there is a focus on understanding how stress and fatigue can negatively impact on all aspects of NTS and outlines methods for avoiding and coping with these factors.
The importance of CRM for safe and effective performance has been recognised in aviation, healthcare, nuclear power, rail and mining. A specific version of CRM is taught in bother naval and commercial shipping, referred to as Bridge Resource Management. However, it is unclear from the report whether the crews had received such training.
What can we learn?
Firstly, operators do not intend to take the wrong decision and understanding why an operator has a certain awareness or made a specific decision, and the process that has led them to this, is vital for learning from an incident (Dekker, 2015). Rather than creating a culture of blame. In most instances the incident is much more complex than it seems at first with multiple, interacting factors.
Secondly, it highlights the need for clear communication procedures on shipping vessels to support shared awareness. This has been recognised by both vessels involved with amendments to procedures for the use of VHF for collision avoidance. Guidance for this is widely available from industry bodies and regulators.
Thirdly, and most importantly, this incident highlights the importance of non-technical skills for safe and efficient performance. The value of CRM training has been recognised by the manager of Seafrontier who has taken a number of steps to train its personnel in bridge and crew resource management. I am gladdened that this action is being taken and offer reassurance that there is a wealth of guidance and expertise available to do this.
It shows that even in an industry in which there is suitable training and support available, it must be utilised to be effective.
References
Dekker, S. W. (2015). The danger of losing situation awareness. Cognition, Technology & Work, 17(2), 159-161.
Flin, R., Martin, L., Goeters, K. M., Hormann, H. J., Amalberti, R., Valot, C., & Nijhuis, H. (2003). Development of the NOTECHS (non-technical skills) system for assessing pilots' CRM skills. Human Factors and Aerospace Safety, 3, 97-120.
Kanki, B. G. (2010). Communication and crew resource management. In Crew Resource Management (Second Edition) (pp. 111-145).
Marine Accident Investigation Board (2018). Collision between Huayang Endeavour and Seafrontier approximately 5nm west of Sandettie Bank, English Channel. Available from: https://www.gov.uk/maib-reports/collision-between-bulk-carrier-huayang-endeavour-and-oil-tanker-seafrontier
Roberts, R., Flin, R., & Cleland, J. (2015). “Everything was fine”*: An analysis of the drill crew's situation awareness on Deepwater Horizon. Journal of Loss Prevention in the Process Industries, 38, 87-100.
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