Enclosure to Officer in-Charge ND School

Letter 805/T/15 dated 04 Jul 23

SEMINAR ON ENHANCING IN’s SAFETY CULTURE

COLLISION BETWEEN FRIGATE AND FISHING VESSEL AND SUBSEQUENT

SINKING OF FISHING VESSEL OFF MUMBAI – DEC 13

Introduction

1. The safe conduct of a warship at sea is more than accurate navigation from
position to position. Controlling the movements of a ship at sea requires capable
officers, good organisation and a clear understanding of the principles of safe conduct
and precise ship-handling1. Navigation incidents are the result of human error caused
by poor management, even if material failure is a contributory factor. Incidents normally
are not an outcome of a singular mistake but a series of human errors; elimination of
any one of these errors by better planning/ management of the overall situation would
have broken the chain of events and prevented the incident. The study 2 as depicted in
the diagram below indicates that majority of the accidents were due to human errors.

2. Human error in navigational incidents, in the form of poor management, occurs in

three broad areas of Planning (Clarity of planning, Capability of people and
1
Art 0101 (b), p 1-3, BR 45 (4) ed Dec 2008
2
Source – Det Norske Veritas (DNV), Norway
 2

Communications), Procedures and Execution. The analysis of incidents has identified

that the management of ‘Clarity’, ‘Capability’ and ‘Communications’ are particularly
important and the following questions should always be considered by the CO and NO
when planning Navigation3:-

(a) Clarity of Planning. The following is relevant: -

(i) What is the purpose of the manoeuvre? How is the manoeuvre to
be carried out?

(ii) Has the right level of planning been applied? Is the plan based on
sound facts or on scanty information and assumptions? Is the plan sound
overall, and as simple as possible in the circumstances?

(iii) Have potential consequences of any lack of planning been thought

through?

(b) Capability of People Participating. The following is relevant: -

(i) How experienced and worked up are the Bridge Teams?

(ii) How capable are other participants (eg tugs, pilot etc).

(iii) Have others eg ships in company, shipping, fishing vessels etc

been considered?

(iv) How tired/ fatigued are key personnel and can they operate
effectively?

(v) Is there an adequate margin of safety in the plan to allow for all
these factors?

(vi) Overall, is everyone capable of executing the plan safely?

(c) Communicating the Plan. The following is relevant: -

(i) Are the instructions clear?

(ii) Will the instructions be issued in time to be understood and

briefed?

(iii) Will ships joining (or in) the formation (or in vicinity) have all the
information they need?

3
Art 1913, BR 45 Volume 1 ed 2008
 3

Aim

3. The aim of this paper is to bring forward and gather a few mitigation measures to
enhance safe navigation onboard. Towards better integration and practical orientation,
the recommended measures are explained with the help of an actual incident which
occurred in the Indian Navy in Dec 13. The case study selected (Collision between a
frigate and Fishing Vessel) is merely a tool to elucidate the importance of safe
bridgemanship and to recommend measures to enhance bridge resource management.

Enhancing Safe Navigation Onboard

4. Accidents/ Incidents at Sea. Analysis of case studies reveal that almost

40% of accidents occurred in pilotage waters whilst a major 60% at High Seas or during
Coastal Navigation4. This is more relevant to IN wherein majority of the incidents have
occurred in pilotage waters.

Ground-
ing
( Pi-
Collision lotage)
(High 28%
Seas)
40%

Ground-
ing
( Passage)
Collision (Pilotage) 17%
15%

5. Bridge Organisation. Bridge Organisation aims towards effective utilisation

of all resources (human and technical) for safe execution of the plan. It focuses on skills
such as teamwork, communication, leadership, decision-making and resource
management towards improved situational awareness for safe and efficient conduct and
appropriate response to contingencies. The following measures are relevant with regard
to effective organisation: -

(a) Maintain situational awareness, acquire relevant information early and

anticipate contingencies while executing the plan.

4
American Bureau of Shipping 2003 ‘Review and analysis of accident data base 1990 – 1999 data’
 4

(b) Monitor execution of plan to make appropriate adjustments and

corrections.

(c) Share a common view (within the Bridge and AIO team) of intended
conduct and agreed procedures.

(d) Clear understanding of chain of command, decisions and instructions.

(e) Develop and use a plan to anticipate and manage workload and risks by
defining manning levels.

(f) Define roles and responsibilities and develop a sense of involvement in

problem solving.

(g) Recognise the development of an error chain and take appropriate action.

(h) Avoid pre-occupation with minor technical problems thereby losing sight of
the bigger picture.

6. Ineffective Bridge Organisation – Common Reasons. Inefficient Bridge

Organisation and its weakness are a major cause of navigational incidents. Common
errors and inadequacies leading to ineffective Bridge Organisation are listed below: -
(a) Failure to communicate intentions and plans.

(b) Deficiencies in skills and consequently failure to recognise and handle

emergencies.

(c) Failure to utilise available data and notice deviations from standard
procedures.

(d) Inadequate challenge and reply response, because of inadequate

personal skills or failure to create an environment that encourages personnel on
watch to seek clarifications when in doubt.

(e) Pre occupation with minor technical problems and failure to delegate
tasks, assign responsibilities and set priorities.

7. Measures for Effective Bridge Organisation. The Commanding Officer

should give careful consideration to the qualifications, experience and competence of
NO, OOW and ORO regarding the conduct, control and execution of navigation, to
decide what degree of authority to delegate and how much personal supervision they
require. The Command organisation to conduct the ship’s movement should be well
established. The following are relevant: -
 5

(a) It is good practice to promulgate the minimum essential posts to be

manned under various degrees of readiness. Any shortfall should be
authorised by the Command post deliberate risk assessment.

(b) The Bridge, Pilotage and SSD organisation for different situations is
highlighted in Ch 19 of BR 45 (1) edition 2008. This should be promulgated with
allocation of specific responsibilities and brought into force on appropriate
occasions. The bringing into force (time and/or position) is an important decision
point in planning process and should engage attention of the Commanding
Officer.

(c) Adequate workup should be undertaken for the team’s coordinated

functioning. This includes posts like Blind Pilotage, SSD OOW, anti-collision plot,
echo sounder operator, lookouts etc.

(d) Organisation for Manoeuvres. Sample format for Command and OTC
organisation for manoeuvres are defined in BR 45. These are available for
guidance and may be suitably adopted based upon individual competence and
state of workup5.

(e) Urgent Relief of OOW by the NO . The CO may allow an experienced

NO to relieve an OOW in times of urgency, without prior consultation with the
CO; if so, this should be authorised in Captain’s Standing Orders 6. The Captain
should be informed immediately upon exercise of these powers.

(f) Bridge – Ops Room Integration. Effective integration of Bridge and

Ops room team is an essential pre-requisite of streamlined watch-keeping
organisation. It is important that the Bridge and AIO team shares a common view
of the intended activity/evolution. Attention to sensor management and collation,
compilation and presentation (format, accuracy and frequency) of a SITREP is
essential.

8. Situational Awareness. Situational awareness is the ability to construct a

mental model on what is happening at the moment and how the situation will develop. It
is important to correlate what is ongoing to what has occurred in the past and what may
occur in the future.

9. Service to Command. Service to Command by Navigating Officer during

conduct of pilotage or special close quarter manoeuvres at sea is a critical component
of Bridge organisation.

10. Action on Making a Mistake . If a mistake is made by the NO or anyone else

during conduct of pilotage, it should be reported immediately. If in any doubt about the
5
Art 0451 p 4-29BR 45 Vol (4), ed 2008
6
Art 0114 (d), p 1-16, BR 45 Vol (4), ed 2008
 6

vessel’s immediate safety, consider taking way off all together. The NO (and the entire
team) must always be scrupulously honest and never try to bluff out of an uncertain
situation. The NO’s pride may be dented by admitting error, but that is better than
denting the ship7.

11. Special Sea Dutymen. Special Sea Dutymen (SSD) by the very nomenclature
implies that each individual of this organisation is charged with a specific responsibility
for safe conduct of an activity/evolution. Therefore, personnel must be qualified, trained
and selected based on demonstrated competence. However, vertical specialisation of
select few is not desirable. Commanding Officer must ensure that adequate numbers
are trained for each post so that re-organisation can be effected as and when required.

12. Completion of SSD Check Off List . SSD OOW should undertake/ monitor
check off list required to be completed prior to an evolution. Actions not completed,
should be brought to the notice of the Captain in sufficient time.

13. Briefings. Briefing of SSD personnel prior to an evolution should clearly

articulate the Command’s intentions and plans 8, for common understanding and
synergy in actions. The following are relevant: -

(a) Conduct briefing at a suitable time. This should allow for full participation
and full attention.

(b) Absence of an individual from briefing must be made known to the

Command. Such personnel should be briefed separately.

(c) Breakdown drills and emergency action should be discussed, as

applicable in the given context and scenario.

14. Communication. Analysis of IN incidents brings out that in many cases

required information always existed but was not available, at the right time, to those who
needed it. The input was either not received or was misunderstood. The following are
relevant: -

(a) Information should be conveyed when needed, understood and

acknowledged by the receiver and clarified if required. A common cause of major
incidents is inaccurate, incomplete, ambiguous or garbled messages.

(b) Maintain a common language (set of orders/reports) so that

communication is clear, easier and quicker. All SITREPS should be
acknowledged. The Originator of SITREP should repeat it, if no
acknowledgement is received.

7
Art 1324 (d), p 13-47 BR 45 (1)(2) ed 2008.
8
Art 1312(u)-(w) p 13-16, BR 45(1)(2) ed 2008
 7

(c) Ship’s company and important posts like Ops Room, MCR, and ASP
should be kept informed of progress of activities/ evolutions. Such an action will
elicit appropriate and prompt response.

(d) Any change in plans should be discussed with relevant personnel and
disseminated at the earliest.

15. Challenge and Reply. A culture of ‘Challenge and Reply’ should be

encouraged onboard. Personnel on watch should challenge (cross check and cross
question) inputs/ reports in order to enhance each other’s performance. Example of
such a process is mentioned below: -

(a) Challenge and Reply - CO and NO. Wheel and engine orders given by
CO whilst making an approachto berth are counteracting and challenged by NO.

(b) Challenge and Reply – OOW and ORO . CMA reported by Ops Room is
challenged by OOW based upon visual (bearing) assessment.

16. Captain’s Night Orders. Captain’s Night Orders should leave no ambiguity for
the OOW. ‘Maintain track and DR’ has different implication than ‘maintain course and
speed’. OsOW must be encouraged by the Command to clarify any ambiguity and seek
assistance when in doubt.

17. Fatigue. Irregular sleep and inadequate rest may lead to fatigue which in a way
is routine factor on many ships because of various reasons. All watch-keepers should
be cognisant of Fatigue9 factor and they should be encouraged to bring it to the notice of
CO/EXO/Senior watch-keeper if unable to discharge OOW duties due to fatigue. CO/
EXO should continuously judge fatigue level of watch-keepers and manage/ amend
watch roster accordingly.

18. The afore-mentioned guidelines are the result of efforts to collate the available
practical experience onboard, however, it will be impossible to pen down the lessons
learnt in the given format. Let us try to understand further measures to enhance Safe
Navigation onboard with the help of an illustrated case study.

Case Study on Collision between Frigate and Fishing Vessel

19. Narrative on Event. A frigate, during fleet breakout operations at night,

collided with a fishing vessel. The frigate was stationed, 1 nm on starboard bow of the
main body, for providing flank protection. The ship had initially planned her transit during
the Break out operations at 12 Kn. Since it was night and break out would have taken
place at about 0100 h on the same night, frigate intended not to close Carrier to less
9
Art 1913(b) Planning – Capability of People Participating, p 19-8, BR 45(1)(2) ed 2008.
Fatigue Risk management is discussed at Ch 6, p 6-2, BRd 45 (4), ed Nov 2016 Ver 1.
 8

than 1.5 Nm. Accordingly, frigate was keeping 1.5 to 2 Nm on the starboard bow of
Carrier. The formation was transiting through dense fishing traffic at night at 15 kn. At
about 2115h, a fishing boat collided with the Frigate and capsized.

20. Sequence of Events. Sequence of events resulting in capsizing of the FV is

depicted below: -

(a) 2040h – CO and NO proceeded for dinner.

(b) 2054h – Radar gained contact of FV (not reported by anti-coll / ops room).

(c) 2104 h– Faint light of FV visible on CCTV (not reported by visual lookout).

(d) 2106h – Frigate collided with FV and the boat capsized.

21. Situation onboard Fishing Vessel.

(a) The fishing boat was proceeding at 6 to 6.5 kn, at the time of impact.

(b) FV crew was engaged in fishing activities and operations. There were no
lookouts onboard FV.

(c) FV did not had any bright lights visible outboard.

(d) The master of Fishing Vessel, claimed to have switched on the signal
lights, side lights and tube light on the boat and one flashing light on the dinghy
being towed behind at about 1930 h ie, well prior the incident. However, only one
dim light possibly on the mast of fishing boat is perceptible about five minutes
prior collision as recorded on CCTV. It is possible that all lights on the fishing
boat were switched off to facilitate the boat’s fish locator who sits on the mast to
lookout for fish schools in water. The lights may have been switched on
subsequently once the crew found the frigate closing rapidly. Though the crew
stated that the frigate approached from boat’s stern, the facts and CCTV footage
reveals that crew of fishing boat had sighted the ship but did not take any
avoiding action.

22. Situation onboard Frigate.

(a) Captain and NO had proceeded for dinner after clearing dense fishing.
EXO was taking night rounds.

(b) The ship’s nav radar had picked up contact 12 min prior incident.
However, the same was not reported by Ant-Coll reporter.

(c) ECDIS displayed the contact with a flashing alarm. The OOW/ AOOW did
not noticed the alarm.
 9

(d) CAAIO displayed the contact closing from bows. ORO and Ops Room
Watch in-Charge failed to notice and report the contact.

(e) Bridge CCTV recorded a faint light of FV closing from port bow four
minutes prior to the incident. However, no light was sighted by OOW and
lookouts.

23. A short brief on Findings.

(a) Personnel.

(i) OOW. A young Lt who had enough experience of 6 months

onboard was performing OOW duties. Serial Coastal Navigation was in
progress as per WEFDEP and the OOW instructed his port lookout to
report a light House in vicinity for visual fixing. CO and NO were in bridge
as avoiding action was being taken against fishing crafts in the vicinity of
the ship. The CO had expected that the ship would encounter extensive
fishing activity off Murud Janjira. Since the ship was about 20 to 25 Nm
South of Murud Janjira by 2040h, the CO did not expect much fishing
activity from that point of time onwards and proceeded down for dinner
after ascertaining that his OOW is comfortable in handling the situation.
Nine minutes past ie. at 2054 h, though the anti-coll had unknowingly
tracked the fishing vessel closing on steady bearing, he failed to report it
to OOW. The lookouts also failed to report any vessel in the ahead sector
though a faint light of fishing vessel was visible on ship’s centerline CCTV.
At 2106h, heavy vibrations were felt from the port side of frigate. And the
duty life buoy sentry reported noise of people shouting in the water
adjacent to ship’s stern. Further a capsized fishing boat was seen in the
water 20-25 meters astern of the ship.

(ii) ORO/Ops Room Organisation. The ORO had closed up 2000h

and his Ops room in-Charge of the rank of PO RP 1 was responsible for
manning both BIUS as well as MDA. The tracks of radar Manta was not
being generated on BIUS Arm 3 in Ops room at that time and was
resolved by the maintainers by 2040h. However, ORO did not make any
SITREP or report to the Bridge at any time. The contact was clearly visible
in the replay of BIUS Arm.

(iii) Anti-Coll Reporter. The anti-coll reporter was manning one of

the nav radar, but was not conversant with the display of radar and did not
know the controls to adjust the radar picture appropriate to prevailing
circumstances and conditions. ECDIS on the bridge was not being
manned and no effort was made at any point to ensure the same, given
the prevailing navigation situation. A dedicated operator on the ECDIS
 10

may have warned the OOW good time that there was one contact steadily
closing the ship from 2054 h onwards till the time of collision. Though the
anti-coll reporter had stated that he was not tracking any such contact at
all, However, this contact could not have been painted on ECDIS unless
the anti-coll reporter was tracking it.

(iii) Reports by Lookouts. Whilst Stbd lookout reported contacts

every 15 – 20 min between 2000h to 2106 h, port lookout just reported
there were a large number of boats and reported relative bearing. Further,
the OOW digressed the attention of lookout from looking out fishing
activity to raising of Tolkleshwar Lt. Both the lookouts failed to notice the
fishing vessel closing the ship fine on port bow continuously since 2104h,
when its single light became faintly visible on CCTV.

Recommendations.

24. Common mistakes that can occur during conduct of navigation and pilotage have
been reflected in a series of do’s and dont’s in BR 45 Vol (I) (Part II). Analysis of
navigational incidents at sea re-confirms this list. The succeeding paragraphs along with
recommendations are a reiteration of these points, which have emerged with regularity
as cause of navigational incidents.

(a) Bridge-Ops Room Integration. The roster of OsOW and watch

keepers must be drawn up with judgement to meet requirements of prevailing
situation and the same is to be approved by EXO of the ship. Experience and
 11

competence should be taken into account whilst formulating watch roster and the
same is to be discussed between Captain, NO and the senior Watch keeper.

(b) Challenge and Reply Organisation. The aspect of challenge and

reply between OOW and ORO should be implemented/ encouraged wrt the
existing/ developing navigational situation.

(c) Degree of Manning. A higher degree of manning/ readiness as

necessitated by the operations in progress must implemented to ensure
availability of adequate and trained personnel in each watch to deal with
concurrent navigational situations. Also, closing up of pilotage team as a
standard practice whilst transiting through dense traffic should be considered/
continued with.

(d) OOW Lookout. The OOW should always wear binoculars and keep
an alert lookout as required by IRPCS. He is usually the only officer in the ship
able to see the water around the ship and should make frequent binocular
sweeps. Further, the OOW should ensure provision of additional lookouts taking
into account state of weather, visibility, traffic density, proximity of navigation
hazards, TSS etc.

(e) AIO for Navigation Safety. Maintenance of anti-coll plot, at all times
is mandatory. Contacts should be designated, tracked and reported till well past
and clear.

(f) Contact Movement Assessment. Anti-coll reports should be

visually correlated and each vessel sighted should be assessed by visual bearing
for risk of collision. OOW should make every effort to identify vessels and sighted
against back scatter. Also, Anti-coll should maintain scan over an appropriate
range scale based upon prevalent visibility and traffic density. It is a good
practice to man two display, one at short scale and other at long scale.

(g) Exploitation of ECDIS. Features of ECDIS be intricately known and

exploited by the OsOW. The inherent habit of muting ECDIS alarm without
deliberate consideration should be curbed.

(h) Alteration to Ship’s Routine. Command teams onboard ships must

have clear orders and understanding with regard to the presence of the
Commanding Officer, the Executive Officer and the Navigating Officer on the
bridge or in the ops room, including staggering of meal timings, in navigational
situations where additional oversight is deemed necessary due to prevailing
circumstances. Activities associated with routine of the ship like night rounds
must be re-scheduled or subordinated if the situation demands so. Alteration in
the ship’s routine to accommodate the needs of safe navigation and efficient
tactical operations must be considered and implemented without hesitation.
 12

25. Keeping a Good Watch. The OOW should be able to judge whether the
ship’s safety is in doubt and confidently voice his opinion. The following is relevant
despite advent of technology and automation of watch keeping processes: -

(a) OsOW should acquaint himself with the plan and passage details relevant
to his watch.

(b) Take bearing and range of a vessel/object when it is first sighted.

(c) Identify vessel/object sighted.

(d) Monitor the vessels relative movement.

(e) Pass downwind or downstream of dangers, anchored ships, buoys or

other obstructions.

(f) Use of non standard communication on MMB and ad-hoc directives to

MVs to alter course without assessing relative motion on Battenberg/ trial
manoeuvre and over reliance on AIS data for track information10.

(g) Ensure safety before alteration to a new course (look before you turn).

(h) Take cognisance of other ships’ movement while keeping station or

following course calculated by Battenberg/ ARPA.

(j) Though no specific rule could be written on how a ship should be handled
while manoeuvring at sea, a cursory look at ethos of safe manoeuvring reveals
that any alteration of course inwards (towards) should generally be avoided while
manoeuvring from forward of the Guide’s beam11.

10
Art 0954 (a) – (e) p 9-34, BR 45 (1)(1) ed 2008
11
Pages 140 &141, Naval Ship Handling by Crenshaw Jr.(Fourth Edition).