201546 Broken on the breakwater
Edited from the official Danish Maritime Accident Investigation Board report (Feb 2015)
A ro-ro passenger vessel was departing a regular scheduled port and was controlled by the Master from the port bridge wing during the backing and turning manoeuvre in the outer basin. During this time an officer and the helmsman were at the centre console. After the turn was completed and the vessel headed on the intended course of 051 degrees, the Master ordered the steering to be transferred to the centre console and for the helmsman to steer 051. The officer pressed the helm TAKE OVER button and confirmed; the helmsman then confirmed he had hand steering. Immediately thereafter the helmsman expressed doubt as to whether he had hand steering. The Master noticed the vessel was still turning to starboard and ordered port rudder. The helmsman confirmed his wheel had no effect and the officer tried pressing the TAKE OVER button once again, but to no apparent effect. The helm Non Follow Up button was then pushed but did not seem to affect steering, so the Master returned to the port bridge wing to try and regain control. This seemed to work and the Master also deployed a bow thruster to stop the starboard turn, but it was too late; the vessel made several heavy contacts with the breakwater. The vessel was returned to berth for safety reasons as several compartments were flooding. The investigation found it highly likely that the centre console helm had been turned to the hard starboard position before the transfer but, because of the darkness and the bad ergonomic design of the helm, neither the helmsman nor the officer had realised this. The helmsman assumed the helm was amidship when control was passed to him. When he put port helm on he simply decreased the starboard helm, which was not enough to counter the starboard swing.
Some other findings of the official report were:
- As the ship was refitted with new and additional equipment, there was little or no analysis of how the operators were working on the bridge. Making new equipment available in an operational environment changes the operational process and even though it can optimise the work, it also introduces new risks.
- The design and operation of the steering system was prone to erroneous actions because it allowed for several different strategies of operation. Also, it was not easy for the operators to see the actual helm angle applied, especially at night.
- The decision to return immediately to berth after the contact was well founded; shortly after the ship was secured the water level in the engine room reached some of the switchboards. After the accident, the ‘old wheel’, previously replaced by the new, smaller unit, was retrofitted around the new wheel and a counterweight was added to make the wheel naturally come to midship if no force is applied. Also, a hook was installed to lock the wheel in the amidship position when not in use.
Editor’s note: It never ceases to amaze how bad ergonomic design seems to be endemic in the maritime industry, as shown by the small wheel and inadequate helm position indication in this case. Additionally, the solutions brought to bear after the accident, although well meaning and probably effective, are a wellspring of improvisation and ironic adaptations. Would the airline industry allow such bad design or for that matter, such ‘handyman’ fixes?
