"Orca" MAIB report

[prv]

Better not to question RKJ or Ellen Macarthur or any other long distance sailor, then. How do they meet the obligation of keeping a lookout at all times?

They don't, and it's a well known omission to which a blind eye is turned on the grounds that they're very unlikely to harm anyone but themselves in mid-ocean. Re-entering busy coastal waters is rightly regarded as a stressful time.

I'm told the RYA have a policy of not formally sponsoring singlehanded events in order not to be accused of condoning illegal activity.

Pete

 

[RichardS]

I do feel that it is rather insensitive to refer to the skipper's wife as somehow being actively involved in this tragedy. The skipper is quite clear that he did not ask his wife to act as a lookout and that she did not expect to act as such as she was there purely a passenger. That was his decision, possibly because of her health, and he is accepting full responsibilty for that decision. I cannot see any justification for looking for any "unstated" reason for his preparedness to accept full responsibility or for speculating on her part in this at all.

I feel extremely sorry for those on the Orca and cannot, in all conscience, attach any blame whatsoever to the skipper or his poor wife for this disaster. As I said previously, there but for the grace of God might go any of us.

Richard

 

[[32511]]

I do feel that it is rather insensitive to refer to the skipper's wife as somehow being actively involved in this tragedy. The skipper is quite clear that he did not ask his wife to act as a lookout and that she did not expect to act as such as she was there purely a passenger. That was his decision, possibly because of her health, and he is accepting full responsibilty for that decision. I cannot see any justification for looking for any "unstated" reason for his preparedness to accept full responsibility or for speculating on her part in this at all.

I feel extremely sorry for those on the Orca and cannot, in all conscience, attach any blame whatsoever to the skipper or his poor wife for this disaster. As I said previously, there but for the grace of God might go any of us.

Richard

+1.
I would not have anticipated the dredger changing course, and I probably would not have realised that it would take only three minutes for the mile separation to become zero.
The mile distance would seem to offer plenty of time for a quick visit to the heads.

 

[JumbleDuck]

Err, lets get this right, HIS WIFE was a passenger then ? surely his WIFE was on talking terms with HIM ? so not a word passed their lips just before the collision then ? in trying not to be too forthright on this particular incident it becomes impossible when someone posts comment like that URG ; so a wife becomes a passenger, for which the Skipper is qualified and so insured to take passengers ?

There is no need to be qualified or insured to take passengers if they are friends or relations.

 

[JumbleDuck]

Yes, I believe the report mentioned that. However, if she was well enough to climb on to the boat in the first place, presumably she would have been able to turn round and look forwards for a few minutes.

Looking sideways might have been more useful.

Serious point: how many non-sailors, assured by the skipper that there was no risk of collision, would be able to tell when the situation changed significantly. Not many, I'll guess, certainly not in the initial stages and possibly not until too late.

 

[Tranona]

There is no need to be qualified or insured to take passengers if they are friends or relations.

Bit slow tonight. See post #57

 

[toyboy]

With such a blind spot ahead of the dredger traveling at 12K+ it is a good job it had not decided to start an early discharge of the spoil as in that case I doubt it would even have been able to see the Queen Mary.

 

[Uricanejack]

An interesting report on a very sad avoidable tragedy. It requires two vessels to make a series of fundamental errors of judgment to create a collision.

Comments which equate the two vessels. lack a fundamental understanding of the difference between a supposedly competently crewed and managed commercial vessel. And pleasure craft out for a pleasant days sailing.

Mr Ingram was a typical British sailor out for a day with his wife on his personal yacht having done the appropriate courses the RYA would recommend for a sailor to skipper a coastal voyage. He had an RYA Coastal Skipper Certificate. His wife, Mrs Ingram was just along for the ride, presumably enjoying an afternoon relaxing in the cockpit, She was not a keen sailor, Not knowledgeable and not expected to take charge of the boat.

A situation which could quite easily describe a typical afternoon sailing on my boat. Sailing is my thing not my wife’s. She enjoys an afternoon on the water but is not “A sailor”.To all intense and purpose I single-hand and she tags along. Is the situation the same on my boat. “Well” maybe not exactly but close enough for me to say “There but for the grace of God”

Mr Ingram made an assumption, An assumption many of us might make. The ship he could see would continue on its current course along the channel the other ship he could see was following. Not an unreasonable conclusion. Unfortunately this assumption was incorrect. He based his subsequent actions upon this incorrect assumption.

Mr Ingram was apparently not listening to ch 71. Most likely he was on ch 16. It's not mentioned in the report if the yachts radio had been on or not so one can only assume. If he had been listening to ch 71 he might have made note of the dredgers intent to leave the deep channel.
How many of us would have been listening to the VTS channel?

My wife and I would have been unlikely to have been wearing our life jackets, unless the weather was bad. I think of them more as a harness. Mine are relatively new, yet unchecked.

Mr Ingram put the boat on auto pilot, I don’t have one, price being the issue. If I had one no doubt I would use it. Probably much as he did. Mr Ingram went bellow for a few minutes to use the head. Most of us might do the same so long as we judged the boat to be safe for the duration of the time involved.

I have no doubt Mr Ingram will spend the rest of his life regretting each of those choices and second guessing his actions.

The MAIB has a very clear mandate to investigate an incident to find out what happened, how it happened and make recommendations to prevent it happening again. Without blame.

You read between the lines, draw conclusions. Point fingers, if you want to, you can blame. I would find it hard to point at Mr Ingram without pointing at myself.

Mr Ingram was just incredibly unlucky to have been in the same little piece of ocean as an exceptionally poorly managed vessel.

Mr Ingram was incredibly unlucky. This Vessel was exceptionally poorly audited by a well reputed Classification society,
The vessel passed its ISM audits because its ISM system was so poor there was nothing in its companies management system for it not comply with.

“If you set the standard low enough anything can be achieved”

This companies exceptionally low. Yet ISM compliant standard. Was to leave everything to the Master. The Master held a certificate from one of the best regarded systems in the world. Mr Ingram was unfortunate the Master of this vessel did not bother to set up a system to ensure there was a proper navigational watch in place.

The Master left this task to the Chief Officer on watch. Who was an equally highly qualified individual. Who without any guidance from the Master or the company failed completely to carry this out.

It is absolutely incredible in this day and age that a British Port. Could issue a Pilot Exemption Certificate to such a poorly managed vessel without any oversight to ensure basic minimum requirements were met. Simply writing a rule and doing nothing about it is just doing nothing.

The ISM code came into being as a result of the failures in management, which allowed the circumstances on the Herald of Free Enterprise which lead to its loss, to exist.

Ms Ingram lost her life due to a complete failure of the ISM code and its system of audits to ensure this vessel was properly managed.

What is incredibly unfortunate. The company who owned and managed this vessel. Despite its poor management, had provided sufficient, well rested, well qualified crew to ensure a proper bridge watch was maintained.

The 2nd officer who was equally well qualified as the Master and Chief Officer was taking no part in the navigation of the vessel. He was doing paper work.

The Chief Officer plead guilty to charges. It would appear. He chose not to comply with the requirements of the Port and its Pilot exemption.

If the MCA wants to point fingers and assign blame.
There is plenty to go around.

Perhaps one might ask.
Why the 2nd officer was doing paper work instead of helping to keep a watch?
Why the Master did not ensure the officers under his command were keeping a proper lookout as required by the regulations.
Why the Master not issue standing orders to comply with the requirements to keep a look out?
Why the management of the company din not have a clear policy and ensure its Master complied?
Why did Beurea Veritas. Issue an ISM certificate to this company and this vessel?
Why did the Port issue a pilot exemption to this vessel without checking?
Why did this vessel get contracted to work on this project without anyone checking it had a system in place to ensure it was properly managed? .

Why did the MCA and port state control not inspect this vessel until after the incident?

 

[JumbleDuck]

Bit slow tonight. See post #57

I'm getting old.

 

[AntarcticPilot]

Hypothetically, say that the skipper had an enlarged prostrate gland. The need to use the loo is immediate and quite painful.

Hypothetically, it could be argued that such a medical condition is sufficient to disqualify you as a single-handed skipper - if it really is that severe.

I agree with both posts, having been in the situation. As DavidJackson says, an enlarged prostate DOES result in an immediate and painful need to urinate. However, it can also result in acute urinary retention, which is an immediate hospital job - normally out-patient, but still urgent and definitely a hospital job, as passing the necessary catheter can be difficult in those circumstances. I've been whisked off to A&E in an ambulance for exactly that, and believe me, it isn't something I'd wish on my worst enemy!

This is all hypothetical, and I'm sure the MAIB would have commented if the skipper was subject to such a debilitating condition as that. I certainly wouldn't go to sea at all if I was still suffering from that condition.

A point of interest is that Tycho Brahe, the astronomer who gathered the data that allowed Kepler to formulate the laws of planetary motion that are behind modern nautical almanacs, quite probably died of acute urinary retention!

 

[30boat]

An interesting report on a very sad avoidable tragedy. It requires two vessels to make a series of fundamental errors of judgment to create a collision.

Comments which equate the two vessels. lack a fundamental understanding of the difference between a supposedly competently crewed and managed commercial vessel. And pleasure craft out for a pleasant days sailing.

Mr Ingram was a typical British sailor out for a day with his wife on his personal yacht having done the appropriate courses the RYA would recommend for a sailor to skipper a coastal voyage. He had an RYA Coastal Skipper Certificate. His wife, Mrs Ingram was just along for the ride, presumably enjoying an afternoon relaxing in the cockpit, She was not a keen sailor, Not knowledgeable and not expected to take charge of the boat.

A situation which could quite easily describe a typical afternoon sailing on my boat. Sailing is my thing not my wife’s. She enjoys an afternoon on the water but is not “A sailor”.To all intense and purpose I single-hand and she tags along. Is the situation the same on my boat. “Well” maybe not exactly but close enough for me to say “There but for the grace of God”

Mr Ingram made an assumption, An assumption many of us might make. The ship he could see would continue on its current course along the channel the other ship he could see was following. Not an unreasonable conclusion. Unfortunately this assumption was incorrect. He based his subsequent actions upon this incorrect assumption.

Mr Ingram was apparently not listening to ch 71. Most likely he was on ch 16. It's not mentioned in the report if the yachts radio had been on or not so one can only assume. If he had been listening to ch 71 he might have made note of the dredgers intent to leave the deep channel.
How many of us would have been listening to the VTS channel?

My wife and I would have been unlikely to have been wearing our life jackets, unless the weather was bad. I think of them more as a harness. Mine are relatively new, yet unchecked.

Mr Ingram put the boat on auto pilot, I don’t have one, price being the issue. If I had one no doubt I would use it. Probably much as he did. Mr Ingram went bellow for a few minutes to use the head. Most of us might do the same so long as we judged the boat to be safe for the duration of the time involved.

I have no doubt Mr Ingram will spend the rest of his life regretting each of those choices and second guessing his actions.

The MAIB has a very clear mandate to investigate an incident to find out what happened, how it happened and make recommendations to prevent it happening again. Without blame.

You read between the lines, draw conclusions. Point fingers, if you want to, you can blame. I would find it hard to point at Mr Ingram without pointing at myself.

Mr Ingram was just incredibly unlucky to have been in the same little piece of ocean as an exceptionally poorly managed vessel.

Mr Ingram was incredibly unlucky. This Vessel was exceptionally poorly audited by a well reputed Classification society,
The vessel passed its ISM audits because its ISM system was so poor there was nothing in its companies management system for it not comply with.

“If you set the standard low enough anything can be achieved”

This companies exceptionally low. Yet ISM compliant standard. Was to leave everything to the Master. The Master held a certificate from one of the best regarded systems in the world. Mr Ingram was unfortunate the Master of this vessel did not bother to set up a system to ensure there was a proper navigational watch in place.

The Master left this task to the Chief Officer on watch. Who was an equally highly qualified individual. Who without any guidance from the Master or the company failed completely to carry this out.

It is absolutely incredible in this day and age that a British Port. Could issue a Pilot Exemption Certificate to such a poorly managed vessel without any oversight to ensure basic minimum requirements were met. Simply writing a rule and doing nothing about it is just doing nothing.

The ISM code came into being as a result of the failures in management, which allowed the circumstances on the Herald of Free Enterprise which lead to its loss, to exist.

Ms Ingram lost her life due to a complete failure of the ISM code and its system of audits to ensure this vessel was properly managed.

What is incredibly unfortunate. The company who owned and managed this vessel. Despite its poor management, had provided sufficient, well rested, well qualified crew to ensure a proper bridge watch was maintained.

The 2nd officer who was equally well qualified as the Master and Chief Officer was taking no part in the navigation of the vessel. He was doing paper work.

The Chief Officer plead guilty to charges. It would appear. He chose not to comply with the requirements of the Port and its Pilot exemption.

If the MCA wants to point fingers and assign blame.
There is plenty to go around.

Perhaps one might ask.
Why the 2nd officer was doing paper work instead of helping to keep a watch?
Why the Master did not ensure the officers under his command were keeping a proper lookout as required by the regulations.
Why the Master not issue standing orders to comply with the requirements to keep a look out?
Why the management of the company din not have a clear policy and ensure its Master complied?
Why did Beurea Veritas. Issue an ISM certificate to this company and this vessel?
Why did the Port issue a pilot exemption to this vessel without checking?
Why did this vessel get contracted to work on this project without anyone checking it had a system in place to ensure it was properly managed? .

Why did the MCA and port state control not inspect this vessel until after the incident?

Agree with all the above but I wouldn't go bellow for more than a few seconds until the ship had passed.I don't trust others to do what I'd think they should do.

 

[Keen_Ed]

Serious point: how many non-sailors, assured by the skipper that there was no risk of collision, would be able to tell when the situation changed significantly. Not many, I'll guess, certainly not in the initial stages and possibly not until too late.

Exactly.

 

[ProMariner]

Tragic accident, destroyed many lives. Heart goes out to all affected.

Agree to all who have said, the yacht was effectively blameless in this, and her skipper already naturally chastised already for any assumptions he made. In the eyes of the colregs, he should have done more, but I think we all agree, his only sin was being in the wrong place at the wrong time, i.e. luck.

The CO was standing his watch, alone, as he is allowed to (in daylight in good visibility), always with the option of calling on other pairs of eyes (and information sources) if required. He deemed them not required, was proven wrong, and immediately took all responsibility for his actions.

Boskalis is one of the best small ship operators in the world, they invest in the best ships, hire the brightest people to staff them, motivate them with a culture of performance and hard work. They support them with one of the most complete safety procedures I have seen from any company. They acted responsibly and openly at all times during the investigation, and had implemented important changes to their procedures within a fortnight of the accident.



Why the 2nd officer was doing paper work instead of helping to keep a watch?

Because the OOW did not deem it necessary.

Why the Master did not ensure the officers under his command were keeping a proper lookout as required by the regulations.

Sure, how was he to analyse every decision, 24/7? Like any master, he is required to satisfy himself the OOW is certified, experienced, and competent. The OOW he took over from found him to be awake, alert, and unimpeded by drink etc. What more do you want?

Why the Master not issue standing orders to comply with the requirements to keep a look out?

Standing orders are in the Bridge Procedure Guide (book of checklists), which the OOW is aware of, and encouraged to use.

Why the management of the company din not have a clear policy and ensure its Master complied?

It did. The Ship Management System is clear, it only failed in this situation to be vessel specific. i.e, the management company would had been better protected had they ensured it was written in the BPG, that there was a big steel fitting infront of the bridge window. You know, in case the watch officer failed to notice it, and make allowances? Pretty sure he knew it was there.

Why did Beurea Veritas. Issue an ISM certificate to this company and this vessel?

Because the company and the vessel comply to all laws required for their operations.

Why did the Port issue a pilot exemption to this vessel without checking?

PEC is issued to Masters and watchkepers, not vessels. Vessels are covered by coding.

Why did this vessel get contracted to work on this project without anyone checking it had a system in place to ensure it was properly managed? .

I am sure they did, quality assurance usually begins about a year before the job starts properly, on a contract like this.


While the responsibility does start and end with the master, the watch keeper of a commercial ship is responsible for ensuring that all responsibilities of the colregs are being dispatched, and has complete freedom over course, speed, and use of information sources and staff to ensure this. Had the watch officer not manned up, he could have put a lot more blame on the vessel, the master, and the company. For this, I give him respect. He had a moment of inattention, failing to do a proper visual sweep before the course change, then failed to make use of a lookout or bridge wing after the course change. For this, he has lost an entire career, his reputation built up over decades. This is how it should work, and will act as a warning to a whole generation of watch keepers in the coastal trade. I fail to see the need for further finger pointing.

 

[Cruiser2B]

I agree, it seems illogical to go below without asking even a 'passenger' to move from facing aft and keep a lookout forward and call him for anything untoward, after all, 5 minutes is not a brief absence. Particularly so with an approaching commercial vessel on a reciprocal course (Orca 260°, Shoreway 090°) with not that much distance between the set courses, when going below.

I skimmed the report, but didn't see this issue addressed - Orca was 10° on the bow of the dredger, roughly reciprocal courses, at a range of 1.6 miles; even if the dredger hadn't altered course, it could be expected to pass at a range of about 500 yards within 5 minutes - is that really the appropriate time to go below?

 

[BrianH]

I skimmed the report, but didn't see this issue addressed - Orca was 10° on the bow of the dredger, roughly reciprocal courses, at a range of 1.6 miles; even if the dredger hadn't altered course, it could be expected to pass at a range of about 500 yards within 4 minutes - is that really the appropriate time to go below?

That was exactly my point. We cannot know what was in the Orca's skipper's mind at the time and the guy has to live with his own demons, but I know emphatically I wouldn't have chanced it when sailing single-handed. And it happens regularly where I sail, with dredgers actively keeping the lagoon channels navigable, they have their own agendas that are sometimes incomprehensible.

 

[prv]

Agree with all the above but I wouldn't go bellow for more than a few seconds until the ship had passed.I don't trust others to do what I'd think they should do.

I try to avoid bellowing on the boat

If there isn't someone else vaguely competent on deck then I do start to get twitchy if I haven't looked around for a minute or so - probably comes of doing so much sailing in the Solent! Fortunately Ariam has almost full-length saloon windows at my eye level, which allow me to see nearly all the horizon even if I do go down to the galley or chart table. In Kindred Spirit I used to regularly pop my head out the hatch like a meerkat

I can't imagine visiting the heads for a "sit down job" singlehanded in near coastal waters.

Pete

 

[bedouin]

I skimmed the report, but didn't see this issue addressed - Orca was 10° on the bow of the dredger, roughly reciprocal courses, at a range of 1.6 miles; even if the dredger hadn't altered course, it could be expected to pass at a range of about 500 yards within 4 minutes - is that really the appropriate time to go below?

I have to wonder if when the skipper went below he really expected to be as long as he was.

But the skipper assumed the dredger would stay within the buoyed channel - I do the same when sailing in the Solent, if I see a ship I assume it will stay in the buoyed channel and would have no concern getting within 100yds provided I was outside the channel.

 

[JumbleDuck]

But the skipper assumed the dredger would stay within the buoyed channel - I do the same when sailing in the Solent, if I see a ship I assume it will stay in the buoyed channel and would have no concern getting within 100yds provided I was outside the channel.

Other people have made assumptions about what ships in the Solent would do:

 

[bedouin]

Other people have made assumptions about what ships in the Solent would do:

I seem to remember that was in part caused by the ship starting to turn, then stopping the turn, then turning again

 

[Cruiser2B]

But the skipper assumed the dredger would stay within the buoyed channel - I do the same when sailing in the Solent, if I see a ship I assume it will stay in the buoyed channel and would have no concern getting within 100yds provided I was outside the channel.

But would you go below while passing at that range? At that passing range, I'd be thinking I'd have to watch for potential wake from the large boat.
The MAIB report doesn't address rule 8 at all - I think it's pertinent:

(d) Action taken to avoid collision with another vessel shall be such as to result in passing at a safe distance. The effectiveness of the action shall be carefully checked until the other vessel is finally past and clear.

(my bold)

Even if your action is to "stand on", the rules still require this.