Take Pride in What You Do,
Which Your Future Self Will Thank You For
Capsizing of Roll-on/Roll-off Vehicle Carrier ‘Golden Ray’ (2017-built, 7,742 vehicle capacity) at St.Simons Sound, Brunswick River, near Brunswick, Georgia, USA on 8 September 2019, was one of the most expensive marine accidents in history. She partially capsized within 40 minutes after leaving the port of Brunswick with 4,161 vehicles, with a loss of over US$200 million for vessel and cargo. Fortunately, all 24 personnel on board (23 crewmembers & pilot) were rescued, though two crewmembers suffered serious injuries. Wreck removal of Golden Ray off Georgia coast has been reported as the largest in US history and required more than 3 million collective man-hours over 2-yearperiod. The total loss to marine insurance industry is estimated to exceed US$1 billion as wreck removal costs are reported about US$840 million.
NTSB determined that the probable cause of the capsizing of the Golden Ray was the Chief Officer’s error in entering ballast quantities into the stability calculation program, which led to his incorrect determination of the vessel’s stability and resulted in the Golden Ray having an insufficient righting arm to counteract the forces developed during a turn while transiting outbound from the Port of Brunswick through St. Simons Sound.
The NTSB also found two watertight doors had been left open, which caused the vessel to flood after it capsized. The flooding trapped four crew members who were later rescued after 30 hours. Review of the NTSB report indicates that the accident occurred in good weather conditions with no other equipment or machinery error, other than the inaccurate assessment of intact stability of the vessel in the accident voyage and the previous two voyages and not ensuring the water tight integrity of the vessel, prior to departure port.
It’s important for every seafarer in active service and manager on shore in the technical & commercial operations in shipping to read the industry marine accident investigation reports, learn from other people’s mistakes (OPM) and stay alert to prevent losses rather than attempting to learn from their own mistakes or accidents in their company. It’s indeed hair raising to read about the rescue of four engineers and cadet trapped in Golden Ray’s engine room, for about 30 hrs in 680C, who had to cool themselves off in flood water.
NTSB report provides shocking findings and interesting preventive actions for one of the worst maritime accidents in history. The long-term effectiveness of the preventive actions (identified in the report) for the industry is debatable. It’s my belief that unless we inspire people to perform with passion and take pride in what they do (which is applicable to any industry), no amount of hand holding, supervision, layers of oversight and cross checking, micro-managing and auditing will prevent undesired and unsafe outcome from the routine operational tasks.
Safety Issues identified by NTSB
- Improperly calculating vessel stability
- Lack of company oversight for calculating vessel stability
Report cites that the Chief Officer made errors with the ballast tank level data entry into the shipboard stability calculation computer (LOADCOM), which led to his incorrect
determination of the vessel’s stability. Once the Chief Officer had calculated the vessel’s stability, he reported the vessel’s final metacentric height (GoM) to the Master and the company (via the departure report), but neither the master nor the company verified that the chief officer’s calculations met stability requirements.
We can see from the report that Master and Chief Officer were very experienced people with years of experience in rank and operational experience on vehicle carriers.
- The Chief Officer had been on board for about 6 months before the accident. He had been sailing for about 13 years and had been a Chief Officer for 10 years, 6 of which were on a vehicle carrier.
- The Master had joined the vessel, 11 days before the accident. He had been sailing since 1980 and as Captain since 1995. He had been working on vehicle carriers since 2016 and had begun working for the Korean operator in 2017.
All crew were of same nationality (S Korea) and vessel was controlled by S Korean interests. Accidents can happen to any crew of any nationality. However, on this vessel,
manning wasn’t complex with mix crew and onboard operation was expected to be
seamless with single nationality.
The total cargo weight on departure was 8,780 mt with an increase of 94 vehicles and an increase in cargo weight of about 373 mt from arrival Brunswick. The vessel’s minimum metacentric height (GoM) was 2.54 mtrs to have sufficient righting energy (area under the righting arm - GZ curve) from the various post-accident analyses and simulations by the Maritime Safety Council (MSC). Chief Officer reported the vessel’s GoM as 2.45 mtrs to the master. The MSC analysis determined that on the accident voyage, the Golden Ray had a GoM of about 1.76 mtrs, below both the minimum 2.54 meters required for this vessel’s departure condition and the 2.45 mtrs, reported by the Chief Officer. Lastly, the MSC also concluded that on the accident voyage, the vessel had 2,900 mt less
liquid load than the comparable loading conditions approved for the vessel.
Integrated Monitoring, Alarm, and Control System (IMACS) on board also had a GoM
measurement feature, which automatically transferred ballast to heel the vessel
up to 1° to either side and calculated the ship’s GoM.
However, this safety feature was not used. Chief Officer will know how he made the error in calculation and the circumstances for not using the available features for cross check of GoM on board. It appears that the Master didn’t do the cursory cross check either, resulting in the one-man error by the Chief Officer leading to the capsize of the ship under his command and putting lives at grave risk.
Previous Voyage Stability Analysis
The MSC conducted additional analyses to assess the vessel’s intact stability during the two voyages before the accident voyage under the current Master on USA coast. The reports showed that the Chief Officer’s calculated GoM for the vessel was 1.96 mtrs when it departed both ports. MSC’s analyses determined that the vessel likely had less GoM when it departed the previous 2 ports. The Master, who was required by the operator’s SMS “to be satisfied that the ship has sufficient stability at all times,” did not review the chief officer’s calculations or report any issues with the Chief Officer’s calculations to the company.
We don’t know why the Master over relied on the Chief Officer and over delegated this important function to the Chief Officer. He seems to have ignored his checks and balances, even though he had just been on board for 11 days and he may not have known the Chief Officer well. His total trust on the Chief Officer put the lives and vessel under his command in grave danger, despite being an experienced Master. Responsible Masters would never over-delegate and would have their checks and balances to ensure stability calculations were done correctly and vessel had adequate intact and damaged stability as per the approved conditions.
Shoreside personnel from the operator received the information contained within the departure reports but were not responsible for evaluating or checking the data to ensure it was accurate and complied with the vessel’s T&S Booklet
Shore-based Managers can request any amount of data and information from the ship. However, this could also lead to crew assuming that the shore-based Managers are checking the information and will alert crew on errors. Shore-based Managers are better off in not seeking information, which they have no intention of cross checking on shore and alerting crew of discrepancies promptly. It’s not practical for operator to check the GoM of the vessel and alert the crew that they have made error. The cross checks are expected to be done on board by the Master & C/Officer.
The company had no procedures to verify stability calculations, so the Master and company were unaware that the vessel had been sailing without meeting stability requirements during the accident voyage and two previous voyages. The Operator’s lack of oversight and procedures for auditing and verifying the accuracy of their officers’ vessel stability calculations before departure contributed to the Golden Ray not meeting international stability standards.
Shipping companies do hire employees based on their previous experience and it’s not common for seafarers to be trained for their primary responsibilities other than briefing by the company on its safety management system and imparting any identified training requirements based on the employee’s previous performance, vessel’s trade or company’s loss prevention and risk management experience. Report cites that each of the vessel’s officers were experienced at their position, and none of the senior officers were serving in a position for the first time. The operator did not provide official training on crew positions and responsibilities to new crewmembers but instead relied on a combination of newly hired crewmembers’ experience and knowledge as well as on-the-job training, which is not uncommon in the industry. We don’t know whether company audited Chief Officer (serving on board for 6 months) thoroughly for making stability calculations during the internal audit about 2 weeks prior to the accident voyage. Audit was reported without any non-conformities.
C/Officers didn’t need specialized training for the loading computer. It was either learned from colleagues/Master or by themselves with the equipment manual. Operator didn’t have to ask us or ensure on shore whether we did the stability calculation correctly. That was our job, and it would have been an insult to our profession as C/Officer and Master if somebody had asked!
Chief Officer stated that no one else on the ship knew how to use the LOADCOM computer, since calculating stability was the responsibility of the Chief Officer.
Master and a junior officer should have been able to operate the loading computer to avoid a one-man-error and for cross check and career progression training on board. People should place lot of focus and importance in mentoring their colleagues and juniors as it’s our duty to pay back to the society and do justice to our mentors, who developed us to what we are today.
After the Golden Ray heeled, open watertight doors on deck 5 allowed flooding into the vessel and blocked the primary egress from the engine room. Maritime industry saw the Couger Ace accident in 2006 with stability issues during ballast waterexchange. It seems that people are either not reading or not learning from the industry accidents and OPM (Other People's Mistakes).
Company’s SMS had arrival and departure checklists requiring the watertight compartments to be closed. Company’s SMS had arrival and departure checklists requiring the watertight compartments to be closed. However, if the checks in checklists are not physically completed and if check boxes are carelessly ticked off without conducting the checks (tick box culture), no amount of SMS procedures and training can prevent incidents and accidents in any industry.
It seems the officers learned nothing from the capsizing Herald of Free Enterprise immediately after leaving the Belgian port of Zeebrugge on the night of 6 March 1987, killing 193 passengers and crew. The eight-deck car and passenger ferry built with no watertight compartments, left harbor with her bow door open. The ISM Code was approved and introduced after a series of worst maritime accidents.
My favorite question to the seafarers in my role on shore from manager to head of ship management has been, ‘‘what do we expect from the aircraft maintenance staff and pilots of the plane we board”? Without doubt, we expect nothing less than pristine work with utmost precision and sense of duty to offer us a smooth, uneventful flight and safe landing at our destination. Our expectations are also not different from the surgeon who is doing a critical surgery on us or on our loved ones. If our expectations on others require them to work with utmost precision and accuracy, how could we perform ourselves with any less precision? Don’t we have to do ourselves, what we expect from others?
I commend the company for their post-accident initiative to standardize the make and type of stability computer used throughout its fleet, replacing the LOADCOM computer
with a “more user-friendly stability computer system”. However, the ship management companies may not always be able to do this for the ships, they manage for multiple owners, though in house ship managers of owners can. We often hear those enclosed lifeboats with tricky on-load release gear have killed more seafarers than saving lives. Marine equipment and operating systems should be as simple and user friendly for the seafarers to operate them seamlessly. Hope the maritime industry will focus on user friendly systems while exploring the future fuels and engines for achieving net -zero emissions by 2050 to save our planet for our great grandchildren.
These findings and preventive actions will add more systems, checklists, auditors on shore. Unless people take pride in what they do and discharge duties with personal responsibility for their own safety, effectiveness of systems and codes in changing the behavioral aspects (sense of duty and responsibility, safety culture) to turn around the operational excellence in any field may be limited.
We don’t know what went on with Chief Officer and Master to slip up on the important task on Golden Ray. People often tend to point towards others rather than themselves, commercial pressure, and an array of reasons after an accident. Unless seafarers and
managers speak up and think for themselves prior each task, you put your reputation and your family’s livelihood at risk. Safeguard it and don’t let it be tarnished. A study of major maritime accidents such as Cosco Busan, Rena, Costa Concordia, Wakashio point to the fact that “experienced people tend to be end up in high profile accidents, with over confidence and complacency. However, it doesn’t have to be the case if we remind ourselves that accidents won’t give notice and we stay alert.
If we take pride in what we do and do it with utmost integrity, we don't need to make headlines for the wrong reasons.