Monday, April 16, 2018

Lessons learned after passenger ship hits uncharted rock

L'Austral from Ponant Cie

From Safety4Sea

In January 2017, passengers of the cruise ship L’Austral had spent the morning in small boats observing shoreline wildlife on the Snares Islands south of New Zealand.
While the master focused on recovering the boats, the ship inadvertently entered the 300-metre unauthorised zone, which the ship was not permitted to enter and struck an uncharted rock.
The hull was pierced and an empty void space was flooded.

The NZ Transport Accident Investigation Commission (TAIC) issued an investigation report

The rock with which L’Austral made contact was uncharted,
having not been detected during a hydrographic survey of the islands in 1999.

The incident

The French-registered passenger vessel 'L’Austral' arrived off the Snares Islands early on the morning of 9 January 2017.
The passengers spent the morning making shoreline excursions in rigid-hulled inflatable boats, observing the wildlife.
That afternoon the weather became unsuitable for small-boat excursions, so L’Austral rendezvoused with the boats in the sheltered water to the south of the islands to take them back on board.

 GPS position of L’Austral, ship delineation to scale 

While the master was focused on manoeuvring the ship to facilitate the safe recovery of the rigid-hulled inflatable boats, the ship drifted into a 300-metre unauthorized zone, where it contacted an uncharted rock.

Linz NZ 2411 updated raster chart (last ed. February 2018) -see Obstn Rep (2017) addition-
visualization in the GeoGarage platform.
The area where L’Austral struck the submerged rock was surveyed in 1999
to a ±50 m positional accuracy and a ±1.6 m depth accuracy.
Within these parameters it was possible that a rock pinnacle would not have been captured. 
The information captured during this survey was used to produce the paper chart NZ 2411.


A notice to mariners has been published by Land Information New Zealand (Linz) alerting mariners to the existence of an obstruction off Alert Stack, until a full survey can be conducted.
The presumed location of the obstruction off Alert Stack has been added to all paper and electronic charts. 
By the way, Linz has also edited a new ENC after the accident
(NZ 424111 New Zealand - Snares Islands / Tini Heke 25/09/2017 1/22,000)
- Linz had not created any ENC for the area of the Snares Islands at the time of the accident -
NZ424111 viewed in Olex seafloor mapping ECS which nowadays equips the ship (2018)

The rock pierced the hull in an empty void tank, which flooded with water.
The damaged compartment had little effect on the ship’s stability, and the ship was able to continue to another sub-Antarctic island before returning to New Zealand for temporary repairs.
None of the 200 passengers and 156 crew were injured.

Findings

The Transport Accident Investigation Commission found that:
  • The unauthorised zone was a Department of Conservation-controlled zone, where charts indicated dangers unsafe for ships the size of L’Austral.
  • The uncharted rock was in an area that the Commission considers was not suitable for the safe navigation of ships the size of L’Austral.
  • There are deficiencies in the way the crew worked together (bridge resource management), insufficient planning for boat recovery and inadequate monitoring of the ship’s position.
 Extract of paper chart NZ 2411, in use at the time of the accident
Note the area of overfalls, eddies and breakers depicted on the charts for the area south of Alert Stack.
Screenshot from vessel’s ECDIS after the accident.
The vessel’s primary means of navigation was the ECDIS, comprising a primary unit and a back- up planning unit.
The operator’s safety management system referred to French law requiring L’Austral to have a paper chart back-up in addition to the secondary ECDIS unit.
However, the operator had misinterpreted the legislation.
Article 221-V/19 in French law stated that back-up devices for ECDISs could be paper or electronic.
This was not a safety issue as such, as the ship had more than the minimum requirement, that being a primary and a secondary ECDIS, and a folio of paper charts.
(All three systems were up to date). 
Had this area been identified as a no-go area as the chart showed the ‘overfalls, eddies and breakers’ symbol, the ECDIS would have alarmed as the vessel manoeuvred, affording the bridge team time to take avoiding action.

Safety issues
  • Voyage planning and good bridge resource management
  • Unfamiliarity with operation of the ship’s electronic chart display and information system (Sperry VisionMaster FT ECDIS)
  • The Department of Conservation had insufficient maritime expertise applied to assessing risks, given the potentially harsh and sensitive environment in the sub-Antarctic islands and the likelihood that shipping activity will increase in future,

Recommendations

The Commission advised:
  1. That the ship’s operator improve voyage planning, bridge resource management
  2. That the ship’s operator review staff training in correct use of electronic chart display and information systems
  3. That DoC appoint a person to manage safe of navigation in the sub-Antarctic islands.
Photograph showing the CATZOC of the unofficial ENC loaded in L’Austral’s ECDIS.
The ECDIS on board L’Austral was loaded with an unofficial ENC for the Snares Islands,
which had been produced by C-MAP, a Norwegian company.
The C-MAP ENC was derived from published electronic raster navigational charts where the local hydrographic offices had not produced ENCs.
The C-MAP ENC that was in use at the time of the accident is shown in Figure above.
The CATZOC U symbols denote that the “the quality of the bathymetric data has yet to be assessed”.
This low-confidence marker was also used as an indicator that it had not been produced by the local national hydrographic office, in this case LINZ.
The provision of the C-MAP chart portfolio containing unofficial ENCs for loading into L’Austral’s ECDIS should have been accompanied by an alert, warning that some of the charts had not been produced by official hydrographic sources. 
The bridge team on L’Austral did not appreciate that the CATZOC of U shown on their ECDIS at the time of the accident indicated that it had been produced by C-MAP, not by LINZ. 

Lessons learned

The key lessons arising from this inquiry were:
  • An electronic chart display and information system is a valuable aid to navigation.
  • However, mariners need to understand fully and be familiar with all aspects of the system, otherwise relying on the electronic chart display and information system as a primary means of navigation can contribute to, rather than prevent, accidents
    Every part of a ship’s voyage must be planned, and all members of the bridge team must be fully familiar with and agree to the plan.
  • This is a cornerstone of good bridge resource management
    Good bridge resource management relies on a culture where challenge is welcomed and responded to, regardless of rank, personality or nationality.
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