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Safety Lessons from Marine Incident Investigation (Company Report) – No.2 – December 2021
One special personnel was seriously injured after losing balance after the ‘pilot’ vessel ran aground during sea trials. The company investigation report found that the Master became distracted by the special personnel’s sea trial requirements.
At about 1425, whilst conducting sea trials, a class 2C domestic commercial vessel travelling at approximately 20 knots in a northerly direction towards the outside of the channel ran aground. The pilot vessel had one crew member and eight special personnel onboard.
As a result of the grounding one special personnel was seriously injured and treated for head injuries. The injured individual was evacuated by the attending Volunteer Sea Rescue Group vessel to a shore-based ambulance and transported to hospital for treatment.
The investigation identified the following contributory factors:
- The vessel was slipped in the morning of the sea trials to change pitch plastics on the propellers with time pressure placed on the master to complete this task prior to sea trails.
- The sea trial manager made a belated requirement for the vessel to be alongside at a pre-arranged time reducing the sea trial period.
- There was a perceived influence on the Master by the special personnel involved with the sea trials to complete sea trials documentation.
- The Master decided to navigate outside the marked channel to avoid a barge at anchor resulting in the vessel running aground at speed, contravening COLREGS, Rule 6 (Safe Speed).
It needs to be recognised that events such as slipping the vessel to change propeller pitch plastics and insisting on reduced sea trial time is likely to lead to time pressure on the Master and crew.
It also needs to be recognised that competing requests regarding individual sea trial requirements in a time pressured environment will likely result in the Master’s distraction and subsequent errors that resulted in the grounding.
Following this incident, the company instigated a detailed review of the company sea trial process for post refit and new builds and distributed a staff notice to all group Masters regarding Safe Speed.