An incident where a cross-channel ro-ro ferry lost control during departure in severe weather, ultimately grounding after a series of misjudgements.
Incident overview
Background of ship and voyage details
The 30,635 gt ro-ro, built in 1991, is registered under the United Kingdom (UK) flag, and has an overall length of 179.7m. This ro-ro was employed as a cross-channel ferry, making several return journeys per day between Dover, UK and Calais, France carrying a mixture of passengers with cars and freight.
The ship was powered by four main engines, driving two shafts fitted with controllable pitch propellers. To assist in manoeuvring, two bow thrusters were fitted, and steering was augmented with high lift rudders.
As the ship traded exclusively in the North Sea Sulphur Emission Control Area, the fuel used on board was ultra-low sulphur fuel oil (ULSFO), having previously used marine gas oil (MGO) until around six months before the incident. Since the change of fuel type, there had been an increased frequency of problems noted with main engine reliability, including difficulty in starting and clutching in, engines alarming on overload more frequently, and reduced power output.
Summary of the incident
On the day of the incident, the ro-ro ferry was making a routine crossing from Dover to Calais. A storm was causing severe weather conditions in the Dover-Calais Strait, with gale force winds reaching 30–40 knots, creating difficult manoeuvring conditions.
Due to the difficult conditions, the first attempt at berthing in Calais was aborted, and the master requested tug assistance prior to undertaking another approach to the berth. Whilst the master was manually controlling the ship’s heading, bow thruster number one (of two) tripped, however it was made available again within five minutes and it was believed that the thruster tripped due to the excessive demands placed upon it.
The ship eventually berthed at 1033 and commenced disembarkation of freight and passengers, before embarking the freight and personnel for the return journey to Dover.
Loading was completed at 1116 and the crew commenced preparations for departure. The delays in berthing meant that the ship was now behind schedule, with the departure originally scheduled for 1035.
Despite the difficult conditions, the master determined that tug assistance would not be required for departure. Against company procedures, no formal pre-departure briefing was held with the bridge team to discuss the planned manoeuvre.
The master then assumed control of engines, thrusters and steering at the starboard bridge wing control station. At 1138 the master ordered moorings to be let go forward and aft, and all lines were reported clear by 1140.
The sequence of the images below provides a clear reconstruction of the course of events. At 1141 the ship was manoeuvred astern and commenced swinging the bow to starboard. At this time the wind speed was recorded at 51 knots coming from the starboard side.
At 1142 number 1 bow thruster once more tripped and the main engine indicated a high load alarm. At 1144 the ship’s heading was now almost facing directly into the wind but continuing to rapidly swing to starboard.
At this point the master attempted to check the swing by thrusting in the opposite direction and returning both rudders to midships. Also at 1144, the master requested the helmsman to take control of steering from the central control console and maintain heading towards the harbour mouth.
However, the helmsman initially did not follow the correct procedure for taking control, meaning that his attempts to steer were ineffective and the rudders remained at midships. This was quickly noted by the master and further instructions were given to enable proper transfer of control.
The ship was still swinging to starboard and to counter this, the master ordered full ahead on both main engines and instructed the helmsman to steer south. The helmsman put both rudders hard to port, which resulted in minimal headway and a movement of the stern bodily to starboard due to the nature of the high-lift rudders fitted on this ship.
These actions checked the swing to starboard, but did not result in the required swing to port. The ship was now moving closer to a nearby jetty (designation T1), eventually contacting it at 1146, with the starboard propeller subsequently stopping on overload. The ship drifted ahead and grounded around 20 seconds later in the shallow water to the west of the jetty as shown in the final image below.
Post-incident actions
After suspecting that the ship was aground, the master ordered both main engines to be stopped. The grounding was reported to the local Vessel Traffic Service (VTS), and a check was made to assess damage and any water ingress that may have occurred.
Tugs were requested from the VTS, and by 1206 two tugs were made fast and assisted in preventing any further movement of the ship towards the nearby jetty T1.
The master was able to update the crew and passengers on the situation, and noting that no water ingress was detected, was able to avoid the need to evacuate personnel.
By 1430, the ship had refloated on a rising tide and was towed to jetty T1 where it was made fast as a temporary measure. By 1715 the wind speed had reduced to below 40 knots and having made fast additional tugs, the ship was towed to another berth where all passengers and freight were disembarked.
From the time of the grounding until around 1615 the port was closed.
The damage to the starboard propeller and tail shaft were such that the ship had to be taken out of service and be dry docked for repairs. Jetty T1 was also found to be damaged following the incident.
Investigation findings
The investigation revealed several factors that resulted in the loss of control of the ship, followed by contact with the jetty and eventual grounding. Principally, a series of misjudgements and errors during manoeuvring in challenging weather conditions resulted in an unrecoverable situation.
It was found that the master may have perceived a time or commercial pressure to depart the berth as soon as possible to prevent the ship falling further behind schedule. This appears to have resulted in the lack of a pre-departure briefing with the bridge team, and the master ruling out the option of awaiting tugs to become available to assist with safe departure.
It is noted that the master’s attempt to steady the ship’s heading after swinging around for departure was insufficient in the prevailing conditions, and this was likely made worse by the helmsman’s lack of experience with the use of the high-lift rudders fitted on this ship.
The manoeuvre may have been successful, if both bow thrusters remained available, and the main engines were operating optimally. However, it was noted that there had been problems with the reliability of the propulsion and manoeuvring systems since the ship had switched to ULSFO six months prior to the incident.
Arrival and departure briefing
It is important and necessary to have a thorough briefing on the intended manoeuvring plan to ensure that every individual member of the bridge team is familiar with and understands their roles and responsibilities. This is an opportunity for all involved personnel to ask questions and point out any apparent problems with the intended plan.
The master should encourage personnel to take part fully and treat this procedure with the importance it deserves. This is in alignment with the core principles of Bridge Resource Management.
It is imperative to guard against complacency when a ship visits the same port on many occasions. Ultimately a company’s procedures must be followed and the necessary culture of compliance instituted. The use of internal and external navigation audits, along with VDR review are some of the tools that can assist in checking compliance with procedures.
By failing to conduct a pre-departure briefing, the master lost an opportunity to talk through the plan and open it to scrutiny from others. It is possible that this simple action could have changed the outcome completely.
Investigate any failure of critical equipment
When critical equipment, for example a bow thruster, fails during a potentially hazardous operation, such as berthing, it is not good practice to assume it was an isolated incident.
Where there is insufficient time to conduct a full investigation or fault-finding, the reliability of the equipment should be in doubt and not relied upon for tasks where failure could result in a hazardous situation – such as manoeuvring in borderline conditions.
In this instance, a proper assessment of risk would have recommended that the master should employ tugs or await better weather conditions.
Challenging weather conditions
The effect and limitations imposed by environmental conditions should always be at the forefront of a master’s thinking. Consideration should be given to lowering the acceptable limits for departing when propulsion/steering equipment is unreliable.
In this instance, windspeed was on the limit of what the ship could contend with. The company had arranged for written guidance from senior masters to be shared to allow others to benefit from their experience, and this recommended the use of tugs depending on the wind speed and direction.
However, the master chose to interpret the guidance as providing prescriptive limits, rather than an aid for examining the actual risk facing the ship.
Commercial or time pressure
It is a reality that ships are expected to be operated efficiently, with minimal idle time, and able to meet the ETA at port, or in this instance to comply with a timetable.
Regardless of this, the safety of the crew, passengers, and ship always remains the master’s responsibility. The ISM Code reaffirms that the master has overriding authority in the interests of safety and pollution prevention.
As is often the case, where time pressure was perceived, the result was the opposite of that desired, with the ship having to disembark passengers and freight before going out of service to undertake repairs and survey.
This incident also resulted in the port closure and subsequent impact on other ferry services. Commercial, or time pressure, is never an acceptable excuse to reduce safety standards.
Management of change
Whenever a substantial change is made to an operational procedure, equipment type, or personnel, it should be the subject of a management of change procedure.
Completely changing the fuel type used on the ship can be considered a major change. It is not clear how well this change had been planned, researched, or tested, however multiple problems with the main engines had resulted since the change from MGO to ULSFO.
In this case it appears problems had been persistent for six months, therefore there were sufficient warning signs, but this fuel type remained in use.
Monitoring and reviewing are critical elements of management of change, and when a change is found to be detrimental and unable to correct, it may be necessary to revert to the original system.
Crew training
Appropriate crew training is an invaluable tool for efficient operations and avoiding accidents.
Crew familiarisation of bridge manoeuvring equipment was lacking in this incident, noting that the helmsman was initially unaware of how to assume control from the bridge wing control point and was unaware of the characteristics of the high-lift rudder.
As a minimum, crew members who may be expected to act as helmsman, should be properly trained in the steering modes and any unique characteristics of the shipboard system.
There are also elements of this incident to recommend simulator training for senior officers to practice manoeuvring in stressful and challenging scenarios.
In this instance the master made several questionable decisions, including keeping the propeller turning after grounding appeared inevitable. It can be expected that the more practice a master or ship handler has in manoeuvring and decision making in difficult conditions, the more proficient they will become at making better choices.
Conclusion
The grounding of the ship on 10 December 2017 serves as a reminder that maritime accidents are often caused by many factors, such as extreme weather, technical failures, and human error.
Despite being in familiar waters, the ferry lost control because of strong winds, technical issues, and poor decisions under pressure.
This incident highlights the need to follow safety protocols carefully, including holding proper briefings, making cautious decisions in bad weather, and ensuring that all equipment is fully operational.
While the outcome resulted in no injuries or pollution, the situation could have been much worse. A more serious impact or delays in refloating could have led to disastrous results. The incident teaches the maritime industry the importance of being prepared for unpredictable weather challenges.
From an industry standpoint, the incident showed the importance of Bridge Resource Management and effective team training. New technologies and regulations, like high-lift rudders and fuel standards, bring new challenges that only well-prepared crews can handle safely.
This incident is a clear reminder that accidents can be prevented with better planning and preparation, ultimately leading to safer ferry operations in the future.
Key questions and lessons learned
- What do you believe was the immediate cause of the incident?
- What other factors do you think contributed to the incident?
- What do you believe were the barriers that should have prevented this incident from occurring?
- Why do you think these barriers might not have been effective on this occasion?
- What actions should the master have taken to prevent the incident from happening?
- What critical equipment or processes exist on your ship?
- What possible reason(s) might have led the ship operations from not following the procedures listed in the company’s SMS?