Wednesday, June 07, 2006

Queen Of The North: Human Error

BC Ferries CEO David Hahn is shaking his head.

The Canadian Transportation Safety Board has ruled out mechanical error in the sinking of the Queen Of The North and laid the cause of the incident on human error.

Specifically, bridge watchkeeping officers are stating that they were unfamiliar with the automatic steering control systems. Whether that actually caused the Queen Of The North to slam into Gil Island or not has yet to be clearly identified.

Something that is much more alarming is that the electronic chart information and display system (ECDIS), although functioning, had the display turned off. Soak that up for a minute.

A letter from TSB to BC Ferries lays out the problem.

The letter notes that members of the bridge team had different understandings of how the new steering-mode selector switch worked and weren't aware of how to adjust the electronic chart system display.

The letter says that while the chart system was left on the night of the sinking, the monitor was turned off to reduce glare. As a result, the ship's course was not displayed.
If that dumbfounds you, join the club. I command ships for a living. I teach new marine electronic technology to junior officers. The reason for an ECDIS system is to remove the error always present on paper charts and to provide real-time display of the ship's position.

I know some mariners would suggest that the OOW might have been using the radar to determine the ship's position and that is fully acceptable - providing he was doing more than just looking at it. The picture presented on radar, even a modern one, is skewed. The only way to accurately determine one's position by radar is to take a position fix using radar ranges and bearing and then transfer that information to a navigational chart. Any other procedure is a "best guess" and does not meet the standard.

The ECDIS system takes information from the ship's radars, its global positioning system and other data feeds. It provides a "right here, right now" display.

But even ECDIS can be inaccurate. That's why there are windows on the bridge. In a narrow passage like Grenville Channel, at night, doing 19 knots, somebody should have been keeping a good lookout. Hell, Rule 5 of the International Regulations for the Prevention of Collisions at Sea require a lookout at all times.

There is another cardinal rule about watchkeeping in a ship. The Officer of the Watch is required to know how to operate every piece of equipment on the bridge. The OOW is required to be fully aware of the machinery and equipment state of the ship, before taking over the watch. And if he/she isn't completely comfortable he/she does not take over the watch. Period.

Hahn is right.

David Hahn said he doesn't understand why anyone would attempt to sail a vessel - especially a passenger ferry - if they weren't comfortable with its safety features.
It goes deeper than that. I could tell him why, but I'm sure he's going to get an earful very soon.

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