STEP CHANGE FOR SAFETY GLOBAL SHARING DEC 2013 - SAFE NAVIGATION | Page 5

GLOBAL SHARING MONTHLY NEWSLETTER – DEC. 2013 - NAVIGATION
KEY MESSAGE: AVOID DISTRACTIONS AND STAY FOCUSED DURING CLOSE QUARTERS.
WHAT HAPPENED:

Vessel under pilotage in Kaliningrad Channel from Svetly to sea.
Present on bridge: Duty officer, Duty AB, OS, Master and Pilot. The OS was at the helm and as it was the first
time he was at the helm during pilotage, The AB was standing by next to the OS.
At a certain stage the heading was 262° and the pilot gave the order to steer 263°. The OS repeated the order
but misheard it and replied “268°”. The pilot acknowledged so the OS applied helm to steer 268°.
When the heading passed 263° it became obvious that the OS had misunderstood the order and would
overshoot the ordered course, and both Master and the AB reacted. The OS gave counter rudder and brought
the heading back to 263°.
The vessel only overshot the new course by 2°.
WHY IT HAPPENED:

When the pilot gave order he was in the starboard side of the bridge and as such not in the immediate
proximity of the OS. The order was given in a normal voice. The duty officer was at the chart table between
the pilot and the OS. The master and the AB stood close behind the OS. The Master and AB were discussing
steering techniques. It is believed that the on-going dialogue behind the OS, the normal background noise,
the distance between the pilot and the OS, and that the order and reply was given at a “normal” voice was all
contributing factors leading to the OS misunderstanding the pilot, and to the pilot not responding to the wrong
reply.
The duty officer explained that he heard the OS reply “268” but was unsure so he decided to observe and
intervene if necessary. The Master and AB only observed an exchange of orders
Everybody’s attention was immediately focused on the proper execution of order giving and the pilotage
continued without further incident. Master has discussed the near miss with OS, AB and the duty officer
individually and agreed on following learning lessons. 1) For Duty officer: If in doubt should not hesitate to
question the situation. 2) For OS: Speak clearly and adjust voice level to the circumstances. Do not hesitate
to question the order if in doubt. 3) For Master: Take care not to distract the crew, and stay focused on the
present operation.
LESSONS LEARNED:

1) The Bridge resource was not focused on the task at hand. Discussions in the background should be avoided so
that the watch keepers are not distracted.
2) Clear communication and repetition of orders to be followed to avoid miscommunication – BACK TO BASICS.
REMARKS:

ST

31

DEC 2013

AVOID DISTRACTIONS ON BRIDGE – STAY FOCUSED
A Shell Marine Contractors Safety Initiative