UK Marine Investigation Branch (MAIB) has published an investigation report, of the grounding of the general cargo vessel BBC Marmara in the Little Minch, off the west coast of Scotland on 25 July 2021.
The incident
At 1645 on 23 July 2021, the cargo vessel BBC Marmara departed from Foynes, on the west coast of the Republic of Ireland, with 1407 metric tonnes of reinforced concrete beams on board. The ship’s passage through the Little Minch and North Minch to its destination port of Scrabster, on the north coast of Scotland, was planned to conform with the mandatory and recommended International Maritime Organization (IMO) ships’ routeing.
BBC Marmara ran aground on Eilean Trodday because the vessel diverged from the planned track, which followed the recommended route safely to the north of the island. The vessel diverged from its planned track because the 2/O, who was OOW at the time, fell asleep and the barriers preventing him from staying asleep had been removed or disabled. This section of the report analyses the circumstances that led to the 2/O falling asleep and the effectiveness of the SMS in controlling onboard procedures, namely the consumption of alcohol, presence of a lookout, use of the BNWAS and voyage planning, and the management assurance of these practices. The lack of intervention from Stornoway MRCC is also assessed.
Management of onboard safety procedure
Alcohol
It is unknown how much alcohol the 2/O consumed before going on watch; however, even before drinking the beer given to him on the bridge, he would likely have been significantly influenced by the effects of the alcohol he consumed during the 3 hours in the AB’s cabin. The consumption of alcohol would have increased the 2/O’s proneness to sleep during a period of circadian low25. At 35% the alcohol content of Jägermeister significantly exceeded the 19%
permitted in the Briese SMS, which prohibited on board consumption of beverages with a higher content and required any purchased as a gift to be handed to the master for secure storage until signing off the vessel. The consumption of a prohibited alcoholic beverage before starting watch shows that the level of control expected by the company was absent on board BBC Marmara. BBC Marmara’s senior officers tolerated alcohol abuse and the 2/O’s further consumption of beer while on watch, courtesy of the master, was indicative of the lack of responsibility at every level of management on board the vessel. The master was ultimately accountable for the enforcement of the alcohol policy, which was not followed as a direct result of his actions and inadequate leadership.
Lookout
The Briese SMS required a lookout to be on the bridge during darkness, when this accident occurred, and in restricted visibility or when requested. However, none was present. The watch schedule indicated that the use of a lookout had been expected and planned for and the hours of work and rest entries and deck logbook records indicated that a lookout was present. However, the 2/O was alone on the bridge from 0050 onwards.
Bridge Navigational Watch Alarm System
The purpose of BNWAS was to monitor bridge activity and detect any operator disability that could lead to marine accidents. The Briese SMS clearly instructed
that, in line with SOLAS V/19.2.2.3, the BNWAS was to be switched on while the vessel was at sea. However, it was usual practice to leave it disabled on board BBC Marmara. The watchkeepers and master considered the need to reset the BNWAS an inconvenience and the master’s decision to leave the system key on the bridge created an opportunity to deactivate it and remove the perceived nuisance.
Previous actions taken on vessel traffic monitoring
The grounding of BBC Marmara was the third grounding of a general cargo vessel within a UK coastguard monitored area in a 3-year period. In response to the
previous groundings (see sections 1.13.1 and 1.13.2) the MCA undertook several actions to improve the performance of VTM, both locally and across the national network. As a result of the actions taken the MAIB made no recommendations to the MCA.
Improvements in C-Scope use, VTM course content and length, immediate local training and policy changes were all immediately achievable, but the effect of those changes, especially in context of the wider national network, will take time. Although these changes all had, and have, their place in the improvement of VTM performance none of them deal with the ability of the MRCC personnel to carry out the task of VTM with respect to cognitive performance, sustained vigilance and the effect the task had on the teams.
Conclusions
Safety issues directly contributing to the accident that have been addressed or resulted in recommendation
- BBC Marmara ran aground because the vessel diverged from the planned track. This happened because the OOW fell asleep and remained asleep and each of the required safeguards in place to prevent this happening, including BNWAS, the presence of a lookout and intervention of the coastguard, had either been removed or were ineffective.
- Abuse of alcohol was tolerated by senior officers and the events leading up to the grounding were indicative of a lack of responsibility at every level of management on board. The master was ultimately accountable for the enforcement of the alcohol policy, which was not followed as a direct result of his actions and inadequate leadership.
- The master and crew believed that manning was insuficient to achieve an acceptable level of maintenance and provide a mandatory lookout when required. With other safeguards removed, the absence of the lookout removed any remaining chance of an intervention when the 2/O fell asleep.
- Records and documentation were systematically falsified on board BBC Marmara to satisfy audit and inspection requirements and avoid sanction or delay.
- Had the BNWAS been active, the alarm should have roused the 2/O after the specified dormant period had expired and the system not been reset. Even if
it had not, the second stage alarm could have alerted the master to the 2/O’s incapacitation and the grounding might have been averted. - Although a successful tool when effectively integrated into bridge systems the BNWAS on BBC Marmara was perceived as an inconvenient distraction; it was usual practice to switch it of if the system key was left on the bridge, thereby disabling a key safety barrier that could have averted the grounding.
- The perceived nuisance of a BNWAS alarm could have been resolved with the automation of the reset function, by integration into the bridge systems or with infrared sensors. This would have removed the need for the system key to remain on the bridge while the vessel was at sea.
Actions taken by other organisations
The Maritime and Coastguard Agency has:
- Conducted a review of its CIP information and guidance relating to recommended routes and voluntary ship reports in the Minches. VTM operators
are now required to ask vessels entering the area whether they intend to follow the recommended routes and are then informed of the next reporting point. The intention is to provide VTM watchkeepers with an appreciation of the intended route of the vessel so that abnormal behaviour can be identified and challenged early. - Reviewed all reporting points in the Minches and tested C-Scope alerts for viability.
- Delivered on-station briefings to all teams at Stornoway MRCC, including a presentation and distribution of an associated information pack on the vessel
routeing and reporting schemes in the Minches. - Carried out an optimisation of the screen set up at Stornoway MRCC, including all operational systems.
- Conducted a Tier 3 review and arbitration panel. The committee found that, while the team at Stornoway MRCC should have been able to conduct SAR and VTM operations with the resourcing levels available, the issues experienced could be replicated in other MRCC.
Recommendations
The Maritime and Coastguard Agency is recommended to:
- Ensure that the hazards of distraction to vigilance-based roles such as VTM and the management of vigilance related hazards are captured in appropriate
training packages, practices, and the Coastguard Information Portal pages. - Carry out a study into the cognitive performance needed by coastguard teams to successfully maintain the VTM function throughout the national network and implement the findings of the study when considering the future management of the network.
Briese Schifahrts GmbH & Co. KG is recommended to:
- Determine and implement the crew resource needed to avoid a conflict between safe navigation and operational tasks such as maintenance. This
should include a link to safety management requirements to ensure STCW guidance is followed, and a lookout is on the bridge during hours of darkness
and in restricted visibility. - Review and implement the management assurance tools necessary to provide accurate feedback on the effectiveness of its SMS navigation practices, including, but not limited to, the presence of a lookout during hours of darkness or in restricted visibility, the use of the BNWAS while at sea and standards of passage monitoring.
