Atlantic Blue’s safety management system procedures did not require specific off-track limits to be included in the passage plan or otherwise ensure that limits for effective track monitoring were always defined.
The ATSB is satisfied that the action taken by Fleet Management will adequately address the safety issue.
Fleet Management has advised the ATSB that as a result of the incident a number of corrective measures have been, or will be, implemented on board ships managed by the company. These measures comprise action to directly address the safety issue and other action to support these direct measures and to avoid similar incidents. The company has decided to revise its shipboard safety management system (SMS) procedures to include off-track limits. The passage plan will specify these limits for each leg of the passage.
Procedures will require the officer of the watch (OOW) to call the master to the bridge if the OOW is unable to keep the ship within those defined limits. Fleet Management has circulated a safety alert to managed ships highlighting Atlantic Blue’s grounding to emphasise the importance of bridge team management and measures to avoid a similar incident.
The measures include a mandatory risk assessment before the master leaves the ship’s bridge during a passage. The master-pilot information exchange checklist in the company’s SMS has been revised. For a pilotage passage of long duration, the checklist includes identifying critical areas, marking master and pilot call points on charts and briefing the OOW for critical areas and required actions during the passage. Training to support the measures above has been extended to include a process whereby masters and mates undertake a mandatory, 2 day ‘navigational safety course’ before they join a Fleet Management managed ship. In addition, the company has implemented ‘SAFER+’, a behaviour based safety training tool, for its staff. Atlantic Blue’s second mate at the time of the grounding is to undertake another bridge team management course at the next opportunity.
The ATSB is satisfied that the action taken by Fleet Management will adequately address the safety issue.