Border Guard vessel Tursas grounding west at Hanko on 12 December 2016

The patrol vessel Tursas of the Finnish Border Guard touched ground during a fairway navigation exercise west of Hanko on 12 December 2016 at 11:19. The vessel’s right azimuth thruster nozzle hit shallows. The azimuth thruster nozzle was slightly damaged. The damage did not affect the vessel’s functioning. No one was injured in the accident, and it did not cause any environmental damage.

Touching ground was preceded by an error in interpreting the signs by the officer of the watch. Despite corrective manoeuvres, the vessel passed the sign on the wrong side and touched ground.

Information about the rapidly changing situation would have been available from several sources: electronic and paper nautical charts, radar, and a look-out watching the rear, but the officer of the watch did not have the ability to process all information fast enough on his own. In the accident, the observation and information processing related to navigation were largely left to the responsibility of the officer of the watch. On challenging sections of the fairway and in difficult conditions, the duties should be divided among the personnel.

Centralising the work on a single person as well as non-standardised and sparse communication make it more difficult to create correct situational awareness on the bridge. The Border Guard’s instructions, practices and operating culture did not support the division of duties on the bridge. In navigation, the role of the officer is traditionally strong. Navigation is officer-centred, even though human resources would often be available.

During the route review held before navigating the fairway, the personnel on the bridge did not get an impression of a particularly difficult route. Careful preparation by the whole crew to the upcoming task would help with forming correct situational awareness and prepare them for reacting to surprising and rapidly changing situations.

The ergonomics of the vessel’s bridge emphasised the use of electronic navigation systems, even though the instructions required an operating model based on using a traditional paper nautical chart. Ergonomics at work should support the work actually being done. The deficiencies of ergonomics become highlighted in situations that require rapid decision-making.

The crisis instructions of the West Finland Coast Guard did not include instructions for organising a defusing session for the personnel after the accident. The officer had to organise a defusing session independently. Guidance in the correct actions after an accident is provided by detailed crisis instructions containing a checklist.

The Safety Investigation Authority of Finland recommends that

• The Border Guard provide instructions for directing enough personnel for the sea watch duties on vessels in difficult fairway sections and demanding conditions and give instructions to divide the sea watch duties so that they are not too centralised on the officer of the watch.

• The Border Guard give instructions to apply the instructions of the Finnish Navy to the bridge communication on its vessels.

• The Border Guard draw up an operating model, in which the actors on the different organisational levels plan together how to learn from accidents and safety deviations more efficiently.

• The Border Guard draw up unit-specific crisis support instructions that include instructions for organising defusing and debriefing instructions for the personnel and prepare the required training for it.

M2016-04 Report only in Finnish (pdf, 2.19 Mt)

 
Published 28.7.2017