Two reports outlining a potential for misunderstanding through a lack of closed loop reporting and vague instructions.
What the reporter told us (1):
This report concerns a failure to maintain closed loop communications, vague and open-ended instructions, and failure to comply with company regulations regarding usage of terms and language for standard procedures.
Whilst the vessel was preparing for sea, the master called the engine control room (ECR) from the bridge with an abrupt command, “ECR, start-up”, before closing the intercom. When the master was challenged as to the nature of the instruction, the derisive tone of his reply was not conducive to a modern workplace. When giving the bridge confirmation that the engine was ready for sea, the chief engineer was continually met with monosyllabic answers before the communication was abruptly terminated. In such situations, the standard communications protocol would be to call the ECR, request a specific engine and thrust configuration, which would then in turn be repeated back, thus closing the communications loop.
Later during start up, permission was requested to clutch in the main propulsion plant. The standard operating procedure, according to fleet manuals, would be to briefly stop the cargo operations until it was ascertained that the clutch and pitch system was not causing uncontrolled movement of the vessel. However, once again, the request to clutch in was met with an abrupt “Yes” from the Master before hanging up, even though the CCTV showed cargo operations were in fact continuing.
Having checked that there was no conflict of personalities involved, it was confirmed that the motivation for the report was the strong possibility that a human error related incident would result from this kind of working behaviour. CHIRP wrote to the DPA who discussed this issue internally and responded. The report was acknowledged and followed up internally as per company procedures.
What the reporter told us (2):
I am reporting an incident where the main engine failed whilst going astern at a critical part of the passage. At the time, we were inbound approaching a turning circle prior to berthing. The engine failed to respond to the telegraph order and several bridge alarms were going off. The master and the bridge team gathered around the telegraph, talking to the chief engineer on the telephone. After approximately 2 minutes, the engine finally started going astern.
At that point, the tugs were not connected and the aft tug reported that they had “no crew” (it was Sunday after lunch…), although there was a strong north westerly wind working in our favour.
No pre-arrival engine test was recorded in the bridge or engine logbooks and the second mate was blamed because he had only recently joined the vessel.
Both of these reports reinforce the importance of teamwork, and closed loop reporting in all forms of communication, in order to ensure that messages are correctly understood.
In our opinion, a properly trained bridge team would not all gather around the telegraph and telephone but would respond to the potential threats by assuming individual functions such as: acknowledging the alarms; have one person checking the situation with the engine room; conducting a navigational check such as the possibility of anchoring and ensuring crew awareness, essentially mitigating the danger by supporting the master and preparing for an emergency scenario. The team would then continue to monitor unfolding events and assess and adjust their plans accordingly. These scenarios should all be practiced in table top emergency drills.
The fact that the engine was not tested at pre-arrival is testament to a company failing in its safety culture – as is the blaming of the second mate. The old expression “Say what you do, do what you say…. And then record it!” is particularly relevant here, and blaming an individual is not going to help. What is actually required is discussing what went wrong, then using the lessons learned to ensure that that there will be no repetition in the future.
Closed loop communication should be used in all aspects of our work and this is not limited to communications between the engine room and bridge – it applies equally to tool box talks, safety briefings, and all instructions. This is particularly relevant where the language being spoken is not the first language of either or any of the personnel involved.
CHIRP also notes that it is important to keep communications open at all stages of the voyage. Reports have been received where there is a distinct lack of communication between the bridge and the engine room particularly when under “stand-by” conditions. Sometimes, there is absolutely no communication between “Stand By Engines” and “Full Away on Sea Passage” or vice versa. CHIRP believes that, apart from common courtesy, the engine room have a need to know how approaches and departures from berths are progressing. As an example, why should the engine room be surprised if standby generators start up, when a simple communication would have informed them that deck lights had been switched on, bow thrusters were about to be used, or mooring machinery was about to be activated?