So thanks for posting the safety investigation. I will high light some of the problems with the vessels set up. I have attended many safety seminars and one was on major disasters and why the occurred. Most big events almost always have more than one cause, in fact three or more major factors are usually at play. Such was the case in this disaster. Most think they are brilliant here on the forum saying not having situational awareness was the leading factor, and they would be right, but looking beyound that is also really necessary. And how electronics was set up, training after new installations, etc also came into play. Even us pleasure boaters can learn from this incident. For me as I noted earlier, it affected the decision as how I control my bow thruster.
First the moon phase that was occurring:
Wednesday, March 22, 2006
On this day the Moon was in a Third Quarter phase. Sometimes called a Last Quarter Moon, this phase occurs roughly 3 weeks after the New Moon when the earth is three quarter of the way through it's orbit around the earth.
Visibility was considered good, wind didn't appear to be an issue.
Electronic chart set up [This raises an issue I've never seen discussed here before on raster versus vector charts]
1.10.3 Electronic chart system setup on the Queen of the North
Unlike the electronic chart display and information systems (ECDIS) - for which monitors must meet strict international standards for factors such as brightness, contrast, and colour - the purchaser of an ECS system may use any monitor.
On the Queen of the North, some bridge officers on both shifts found the ECS display overly bright during the night watch. This problem is exacerbated when the system is displaying raster charts,Footnote33 because land is shown as yellow-orange in colour and water is shown in white, regardless of whether the ECS is in day or night display mode.Footnote34 As a result, raster charts are inherently brighter than vector charts when the system is in night mode.
To alleviate this, the crew in a previous season had placed a screen over the monitor. A rotary dimmer was later installed to let bridge officers dim the screen beyond the standard setup brightness option for the monitor, even if night-setting palettes had already been selected. Some officers had developed the practice of dimming the screen, using this dimmer, and brightening it only when they wanted to check their position.
At the time of the occurrence, the ECS was displaying a raster chart, and the display had been dimmed by the 4/O. In addition, the investigation revealed the following points regarding the setup of the ECS on board the vessel:
The chart portfolio for the areas being navigated by the Queen of the North was mostly in raster format.
The navigation-danger alarm was unavailable while the raster chart was loaded.
The cross-track alarm had been manually deactivated around the time of the refit.
The software was configured such that all alarm sounds were deactivated. As a result, active alarms would provide visual warning only.
To defend against the ad hoc modification of parameters, such as alarm settings, the system was provided with a password. However, this password was well known and easily accessible to any who wanted it. Furthermore, BC Ferries had no policies or procedures in place to define the desired configuration of the ECS safety features. This effectively left the system setup at the discretion of each operator.
The waypoint, cross-track, and navigation-danger alarm features available with the other electronic navigation equipment had not been set up or enabled.
This next issue was a biggy, the helmsman (woman) did not know how to turn off the autopilot. Nothing addresses what I am about to say but I think it was possible she had an idea of how to do it, but in the panic in the moments prior to the collision, that knowledge went out the window.
1.12 Steering-mode selector switch
The Queen of the North was in refit from January 2006 until 02 March 2006. Its steering system was modified, and the following items were modernized:
the steering wheel at the aft steering station
the steering-mode selector switch at the aft station
The new steering-mode selector switch, albeit a newer model, was for all intents and purposes physically the same as the original switch. However, the logic and the manner in which the steering system functioned were altered with the installation of the new steering-mode selector switch.
In situations where a replaced system is physically similar to the original system, but where changes have been made to the underlying logic of the system, usability issues may emerge. As a result of negative transfer,Footnote36 significant training can be required to overcome the automatic response associated with the original system logic. This can be particularly important in times of stress, where the original automatic response is evoked because of the physical similarity between the original system and the new system.
Throughout the refit, the C/O of the A watch had remained with the vessel. When the new steering-mode selector switch was installed, a procedure was developed for its use. The procedure and information on the functional characteristics of the new steering-mode selector switch were posted on a laminated sheet immediately aft of the steering wheel at the aft steering station. All deck crew of the A watch were familiarized with the operation of the new switch. The posted procedure did not highlight the fact that the rear steering station was no longer the "primary" station.
At the time of the handover, the C/O of the A watch informed the C/O of the B watch of the replaced switch and advised him of the instructions posted behind the aft steering station. Not all crew (including QM1) of the B watch were familiar with the changes in operation, nor with the rationale for the new system and procedure. The B watch's unfamiliarity with the changes in steering system functionality following the installation of the new steering-mode selector switch was demonstrated by the fact that, subsequent to the accident, various B watch deck crew provided investigators with four different explanations as to the interaction between the forward and aft steering station switches and which specific functions were available at various switch settings.
Following the change in watches, a number of crew members of the B watch challenged the new operational procedure. The master, in discussion with the crew and after testing the steering-mode selector switches en route, decided to use the steering selector system differently than the previous watch, and in a manner analogous to the original system. The B watch wanted the forward wheel to be active when the QM was at the forward station, and it was not active in the A watch system.
In developing their procedures, both the A watch and the B watch were attempting to maintain elements of the operation of the original steering system. However, the procedures for the original system and the procedures used by the A and B watches differed.
Table 1.Procedural differences for switching from autopilot to aft steering station
A Watch B Watch
Original Procedure QM moves the switch at the aft station
from FWD to AFT QM moves the switch at the aft station
from FWD to AFT
Procedure After Change Aft station switch pre-set to AFT
OOW moves the switch at the forward station from AUTO to WHEEL Aft station switch pre-set to FWD
QM moves the switch at the aft station from FWD to AFT
OOW moves the switch at the forward station from AUTO to WHEEL
In the original system and the B watch system, the QM would normally only be required to operate the steering-mode selector switch at the aft steering station.