1. Case study: Grounding of CSL Thames in the Sound of Mull, UK, on 9 August 2011 TAIEX Workshop on Marine Casualty Investigation 5-6 September 2012 David Wheal Principal Inspector of Marine Accidents UK Marine Accident Investigation Branch

3. Notification and assessment Notification from ship owner to Maritime and Coastguard Agency (MCA) Notification from MCA to MAIB MAIB preliminary assessment, preservation of evidence, discussion with shipowner and Flag State Decision to conduct an MAIB safety investigation Arrangements for co-operation agreed with Flag State

4. Stakeholder co-operation MAIB notification to shipowner of legislative basis for the investigation, information for witnesses, documentation request Flag State notification to shipowner of MAIB investigation and request for full assistance and co-operation with MAIB

5. Investigation and briefings Witness interviews (ship personnel) Material evidence collection (documentation) Technical evidence collection (VDR / ECDIS) Team briefing (casualty analysis) Branch briefing (Flag State liaison) Final analysis review (quality assurance) Report consultation (quality assurance) Actions taken Report publication (MAIB / EU / IMO) Safety recommendation follow-up

6. CSL Thames 20,000 GT bulk carrier Sound of Mull Draught 10.63 metres, 12 knots, 290°(T) Daylight, good visibility Master, third officer, helmsman ECDIS:safety contour:10 metres cross-track deviation limit: 0.2 mile anti-grounding:1°, 10 minutes

8. Narrative 1006:autopilot, con to third officer

11. Narrative 1010:early turn towards 314°(T)

13. Narrative 1006:autopilot, con to third officer 1010:early turn towards 314°(T) 1014:sailing vessel bearing 318.5°(T)

15. Narrative 1006:autopilot, con to third officer 1010:early turn towards 314°(T) 1014:sailing vessel bearing 318.5°(T) 1016:continue turn

17. Narrative 1006:autopilot, con to third officer 1010:early turn towards 314°(T) 1014:sailing vessel bearing 318.5°(T) 1016:continue turn 1018:heading 321°(T), small vessel ahead

19. Narrative 1006:autopilot, con to third officer 1010:early turn towards 314°(T) 1014:sailing vessel bearing 318.5°(T) 1016:continue turn 1018:heading 321°(T), small vessel ahead continue turn to 324°(T)

21. Narrative 1006:autopilot, con to third officer 1010:early turn towards 314°(T) 1014:sailing vessel bearing 318.5°(T) 1016:continue turn 1018:heading 321°(T), small vessel ahead continue turn to 324°(T) anti-grounding visual alarm

23. Narrative 1006:autopilot, con to third officer 1010:early turn towards 314°(T) 1014:sailing vessel bearing 318.5°(T) 1016:continue turn 1018:heading 321°(T), small vessel ahead continue turn to 324°(T) anti-grounding visual alarm 1021:two prolonged blasts

25. Narrative 1006:autopilot, con to third officer 1010:early turn towards 314°(T) 1014:sailing vessel bearing 318.5°(T) 1016:continue turn 1018:heading 321°(T), small vessel ahead continue turn to 324°(T) anti-grounding visual alarm 1021:two prolonged blasts 1023:small vessel passes clear to port

27. Narrative 1006:autopilot, con to third officer 1010:early turn towards 314°(T) 1014:sailing vessel bearing 318.5°(T) 1016:continue turn 1018:heading 321°(T), small vessel ahead continue turn to 324°(T) anti-grounding visual alarm 1021:two prolonged blasts 1023:small vessel passes clear 1025:CSL Thames grounds

28. Causes Premature course alteration and continued alteration for collision avoidance No monitoring of CSL Thames’ position and projected track after course alteration ECDIS visual anti-grounding alarm not identified ECDIS audible alarm inoperative

29. Contributing factors Assumed risk of collision Total focus on collision avoidance ECDIS display unit orientation Reliance on ECDIS display for immediate position identification Reliance on ECDIS display for grounding warning Lack of ECDIS understanding Overconfidence

30. Post-grounding actions No use of grounding checklist Follow-up actions not recorded No sounding of general alarm No immediate damage assessment No risk assessment before tank entry Decision to enter breached tank

31. Actions taken Repositioning of ECDIS unit Reconnection of ECDIS audible alarm ECDIS “equipment specific” training Bridge resource management training Onboard ECDIS training to fleet

32. Safety recommendation Introduce written instructions and guidance, and carry out verification visits to ensure -bridge officers understand how ECDIS should be used -officers and crew understand the vessel’s emergency procedures and properly evaluate routine operations after a casualty to ensure new risks are identified and addressed

33. Thank you for your attention www.maib.gov.uk