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28 Mar 2024

The Club would like to draw Members’ attention to an investigation report published by Marine Accident Investigation Branch MAIB UK (Serious Marine Casualty Report No 12/2019), that pertains to an unfortunate incident involving the grounding of a general cargo vessel. 

The Incident

The incident involved a general cargo vessel that ran aground during the early hours of the morning following a series of navigational errors. The vessel was eventually refloated but had suffered significant hull damage. Fortunately, no pollution or personal injury resulted from the incident.

Although there were various contributing factors that led to the incident, the investigation discovered that the Officer of the Watch (OOW) started watching music videos on his mobile phone shortly after taking over the watch (at 0200 Hrs). He sat on the bridge chair, which was positioned where he was unable to monitor or operate any of the bridge equipment. Sitting alone on the bridge in the middle of the night created an environment that posed a high risk of the OOW falling asleep, and it is possible that he did so intermittently between 0230 and 0400 Hrs.

For about two hours, the OOW was unaware of the vessel’s gradual deviation from the planned route. When he realised that the vessel was off-track, there was still ample time and sea-room to regain the planned route. However, he chose an alternative route that took the vessel over a charted reef of rocks thereby placing the vessel in danger.

Despite warnings from the local Coast Guard Operations Centre (CGOC) and the local Vessel Traffic Services Officer (VTSO) that the vessel course was heading into danger, the OOW failed to take appropriate action until the vessel was 5 cables away from the rocks when he worsened the situation by altering course towards the rocks.


Ineffective Safety Management System (SMS):

  • The SMS did not provide any detailed guidance on passage planning or the use of ECDIS.
  • The SMS contained no guidance on the use of mobile phones on the bridge.
  • The SMS did not contain any detailed guidance for the use of ECDIS or other methods for fixing the vessel's position, such as visual, radar, or echo sounder.
  • The SMS did not contain sufficiently detailed guidance or direction for the safe manning of the bridge or utilisation of the navigation equipment.
  • The OOW had consumed alcohol in the evening prior to the incident. The SMS stated that alcohol was not to be consumed in the 4 hours prior to a duty period. Although it is understood that he had stopped drinking more than 4 hours before the watch started, the risks associated with consuming alcohol should not be underestimated. There was no alcohol testing equipment on board and none of the crew were tested for alcohol consumption after the accident.

Improper passage planning:

  • The passage plan did not contain any meaningful details of the navigational hazards likely to be encountered and the methods expected to be used to keep the vessel safe.
  • The passage plan did not contain details of the navigational marks, anticipated depths, or utilise the ECDIS safety corridor or warning sector to give sufficient warning.
  • The passage plan did not require participating in voluntary reporting schemes.

Poor watchkeeping practices:

  • Adjustments had been made to the bridge watchkeeping routine for that particular night, including placing an unqualified cadet to stand watch on the bridge alone from 2300 to 0200.
  • The OOW was a solo watchkeeper during hours of darkness. No additional lookout had been posted.
  • There was no Master’s order book in use on board.
  • Basic tools such as Visual lighthouse fix, Radar fix, and Parallel indexing were not used.
  • The OOW did not call the Master following the vessel’s departure from the planned track, as was required by SMS.

Poor situational awareness:

  • OOW, on the takeover of the watch, deselected track mode steering and switched to standalone autopilot with the heading set at 279°. This decision allowed the Southerly tidal stream to set the vessel off track to the South.
  • Due to a lack of position monitoring, the drift of the vessel went unnoticed. All means of position monitoring were not used. A visual fix (using a lighthouse bearing) could have indicated that the vessel had drifted off its course.
  • To regain the course, the OOW relied solely on Radar data and did not refer to navigational information when making this critical decision.

Poor use of navigational aids:

  • There were no navigational alarms to warn of danger. The ECDIS safety depth was set at 10m, but no safety corridors or warning sectors were selected.
  • Echo sounder incorporated an audible depth alarm. At the time of the grounding, the echo sounder was on; the status of the alarm setting has not been determined.
  • The Bridge Navigational Watch Alarm System (BNWAS) was switched off.


  • The OOW was evidently disorientated.
  • The OOW had consumed alcohol and due to personal matters, was also experiencing some feeling of anxiety and restlessness.
  • When on watch, the maritime officer was seated and alone in darkness on the bridge. All of these factors combined to create a very high risk of the OOW falling asleep.

Falsification of records:

  • Onboard hours of work and rest records incorrectly indicated that the ABs had been conducting night watches as lookout.​​​


  • Procedures should be implemented governing the onboard use of mobile phones and other portable personal devices. This would include investigating the necessity of having Wi-Fi access on the bridge and in other critical working areas.
  • An internal audit regime to be in place to effectively monitor safety management of the vessel.
  • SMS procedures to include detailed guidance on Proper Passage Planning.
  • Ship operators, masters and deck officers on ECDIS-fitted ships are encouraged to use IMO’s Guidance for good practice to improve their understanding and facilitate safe and effective use of ECDIS.
  • A proper lookout is required to be kept at all times. Additional lookout is to be posted during hours of darkness or considering other factors that demand support to OOW to perform his function on the bridge watch to maintain an effective lookout.
  • Cadets or uncertified crew should not undertake duties for which they are not qualified. It is important to ensure that the vessel is always adequately manned, taking into account the minimum safe manning requirement as well as operational needs.
  • If fitted, BNWAS should be used whenever the vessel is underway and at anchor, if appropriate.
  • The most common causes of fatigue among seafarers are lack of sleep, poor quality of rest, stress, and excessive workload. Fatigue affects judgment and the ability to make decisions efficiently. It is, therefore, essential that Members understand the risk of Fatigue and manage it effectively.
  • It is important to maintain positive mental health while working onboard.
  • Proper recordkeeping not only ensures regulatory compliance but also provides vital evidence in the unfortunate event of an incident. Hence it is important to maintain proper records.
  • Fostering a healthy safety culture can promote commitment to safe practices.

This case study has been compiled using the MAIB Serious Marine Casualty Report No 12/2019.