Tuesday, November 12, 2019

A Failure of the Fundamentals in Hjeltefjord

A beautiful ship on a beautiful night ... and a classic series of failures that led to a collision at sea.

Read the whole thing ... but at its core - what was the failure?

Fundamental seamanship.
As a consequence of the clearance process, the career ladder for fleet officers in the Navy and the shortage of qualified navigators to man the frigates, officers of the watch had been granted clearance sooner, had a lower level of experience and had less time as officer of the watch than used to be the case. This had also resulted in inexperienced officers of the watch being assigned responsibility for training. Furthermore, several aspects of the bridge service were not adequately described or standardised. The night of the accident, it turned out, among other things, that the bridge team on HNoMS Helge Ingstad did not manage to utilise the team’s human and technical resources to detect, while there was still time, that what they thought was a stationary object giving off the strong lights, in fact was a vessel on collision course. Organisation, leadership and teamwork on the bridge were not expedient during the period leading up to the collision. In combination with the officer of the watch’s limited experience, the training being conducted for two watchstanding functions on the bridge reduced the bridge team’s capacity to address the overall traffic situation. Based on a firmly lodged situational awareness that the ‘object’ was stationary and that the passage was under control, little use was made of the radar and AIS to monitor the fairway.
The investigation of the collision in the Hjeltefjord in the early hours of 8 November 2018, has found that the bridge team on HNoMS Helge Ingstad may have been somewhat affected by fatigue, particularly considering the time of day. In the absence of systematic logging of working hours and hours of rest etc., it has not been possible to further investigate the degree to which the bridge team may have been affected by fatigue. The Ministry of Defence has initiated the process of establishing protective provisions for sea-going personnel in the Navy.

The Accident Investigation Board Norway recommends that the Ministry of Defence introduce, particularly relating to critical functions, a system to give the Navy a systematic overview and positive control of hours of rest. In addition, a requirement for compensatory measures should be put in place when non-compliance with the provided hours of rest in the civilian protective provision.
No watch is normal. Nothing is standard. No required procedure is redundant. 

Bad things don't happen to other people; you are other people.

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