Karen Danielson
Karen Danielson
In the April 2005 Pilot I included a report into the fatal collision of the Karen Danielson with the Great Belt Bridge pilotmag.co.uk/userfiles/Pilotmag%20281%20(Apr%2005).pdf. The initial accounts into the disaster questioned why the Danish Belt VTS, which had been installed specifically to monitor traffic in the vicinity of the bridge, had failed to prevent the collision. The full report has now been released and the following account contains the main findings. In my
opinion there is a bit of whitewash over the finding that the VTS could probably not have prevented this disaster since the investigators have seemingly revealed that no operators were monitoring shipping on the relevant display for over 30 minutes. If it is considered unlikely that the operator could have prevented the collision even if he had been keenly monitoring the ship it does rather beg the question why bother with having the VTS and expensively manning it since it is seemingly not fit for purpose?
One common factor amongst all the VTS centres that I have visited is that VTS operators are allocated many administrative duties which inevitably distract the VTS operator from monitoring the displays. If the procedural changes introduced in the Danish Belt centre following the collision were implemented as general VTS policy the increase in manpower required to separately cover the administrative
functions could have a significant impact on cost effectiveness of VTS. The following is edited from the official report.
Link to the original pdf illustrated magazine article (Page 10):
pilotmag.co.uk/userfiles/Pilotmag%20287%20(Oct%2006).pdf
The Karen Danielson was a general cargo ship of 3120 grt, built in 1985 and which collided with the Great Belt West Bridge shortly after leaving the port of Svendborg in Denmark.
1715 The pilot left the ship when it was off Thurø.
1815 The chief officer came to the bridge and shortly after the master left to eat and left the chief officer alone on the bridge.
1820 The course was altered to 005°. The speed was 11.5 knots. It was twilight and the weather was clear.
At approximately 1857 hours the ship was due to alter to an easterly course to pass north of Langeland However, the ship continued on a course of 005°.
1907 Karen Danielson collided with the western section of the Great Belt Bridge and the wheelhouse was torn off.
1912 hours the ship transmitted a Mayday distress signal, and only then did the VTS Centre realise that something was wrong. The master was severely injured in the collision and another crewmember was injured during the rescue. Following salvage of the vessel the chief officer was found dead in the wreckage of the wheelhouse. At the post-mortem examination, the result of the alcohol test proved positive Karen Danielson was equipped with AIS and the ship’s movements from departure from Svendborg and until it collided with the bridge were registered by the Royal Danish Administration of Navigation and
Hydrography
VTS Great Belt
When the decision was taken to build the fixed link across the Great Belt it was also decided to establish a Vessel Traffic Service (VTS) system for safeguarding the link. The Admiral Danish Fleet (SOK) is the operational manager of the VTS-system and the operation is based upon an agreement between SOK and A/S Sund & Bælt Holding, which has economic responsibility.
Extract from VTS Great Belt Procedure:
The task of VTS Great Belt is to supervise the Great Belt traffic to protect the bridges spanning the Great Belt and to alarm in time to stop rail and road traffic in case of a risk of collision with the bridges.
According to the watch schedule the team leader should have taken over from operator 2 at the operator’s desk at 1800 hours. Around that time he was however occupied by a telephone conversation and he also needed to finalize some administrative work and did not take over from operator 2 until approximately 1830 hours when operator 2 informed him about the vessels, which were within the VTS area. The team leader was well aware of the fact that Karen Danielson was too large to pass under the bridge.
After been relieved operator 2 went down to the cellar conduct some tests on new VHF equipment. Between approximately 1840 and 1900 operator 2 called the Team Leader in the operations room three times from the cellar to test the new VHF. At around 1900 hours the team leader was also occupied by printing out the pilot lists from the Great Belt Pilots and checking them against the VTS database. This was the normal watch routine. Operator 1 was then in the nearby pantry dishwashing At about 1909 hours the team leader heard a “Mayday” call. He did not quite understand what was said because the voice calling was exited. The exited voice continued calling “Mayday” and the team leader now understood that the ship was Karen Danielson. The team leader therefore looked at the radar monitor and he could not see the echo of Karen Danielson. He then heard that the person calling say that the vessel was locked under the bridge and he then activated the alarms to the bridge traffic watch, the police and the railway remote control centre.
Alarm – Danger of collision
According to the procedure VTS must immediately inform the police, the railway remote control centre in Roskilde and A/S Great Belt traffic watch when VTS estimate, that the navigation of a vessel towards the West Bridge can create a situation of risk to the West Bridge. If it is estimated that within 10 minutes a vessel will collide with the bridge, VTS activate “alarm”. If VTS estimate that there is a risk that a vessel within 10 to 30 minutes will collide with the bridge, VTS activate “collision warning”.
On 3 March at 1917 hours A/S Great Belt received a phone call from VTS Great Belt.
This was followed immediately after by a phone call from the police in Slagelse. At that time the alarm had not been received. The alarm sounded at 19.17.44 -“collision warning” and “alarm” at the same time. At 1919 hours the police closed the barriers onto the Great Belt West Bridge.
Alarm function on the VTS system
There are several automatic alarm functions in the VTS system. e.g. it is possible to insert a zone on each side of the bridge. Echoes from vessels within the zone will activate the alarm. The automatic alarm function has not been used for the last 8 years.
According to the Admiral Danish Fleet the reason for not using the alarm function is that if used it had to be linked to the 10 minutes warning alarm and that the zone thus would be so great that the alarm would be activated constantly due to ships which were not a risk to the bridge.
The team leader on duty at the operator’s desk at the time of the collision, has told the investigators that he had concerns in relation to his work and thinks this, the administrative work with pilot lists and the radio check have been essential contributory factors to his failing concentration and the fact that he did not notice that the echo of Karen Danielson continued on an unchanged course towards the bridge.
The team leader is also of the opinion that the colours on the radar screen are not suitable. The head of VTS Great Belt has told the investigators, that it is possible to use screen adjustments decided by the user. He also advised that the screen adjustments have been discussed at meetings at the VTS Centre. Because it is fast and easy to adjust the screen, they had agreed that each operator should choose the adjustments he or she preferred.
Analyses
The chief officer, who was killed in the collision, did not initiate a turn to the east
at waypoint 107, in accordance with the passage plan despite the fact that the GPS
Navigator had been sounding on the bridge from the time the ship passed
waypoint 107 at 1857 hours and until the collision at 1907 hours. The available
evidence therefore suggests that the chief officer had fallen asleep, some time after
the alternation of course which he made at 1820 hours to 005°.
VTS Great Belt
The VTS Great Belt procedures did not include rules on the watch team’s internal
organisation. The watch had been organised according to regular practise. In the period prior to the collision, only a few ships were in the VTS area. It was not until 10 minutes prior to the collision that something out of the ordinary happened. The fact that the surveillance of the VTS area had been left with only one operator contributed greatly to Karen Danielson’s steady course going unobserved and it also prevented the VTS-centre from trying to contact Karen Danielson and warn that the vessel was standing into danger. According to the Admiral Danish Fleet, the internal watch procedure has been
changed to the effect that there are now always two operators in the immediate vicinity with the operator’s desk. One of them is primarily responsible for communication and the other one is primarily responsible for watching the radar screens.
Plotting
At no time was the VTS-centre in doubt as to the identity of Karen Danielson. The
pilot’ report had been received, there were no other echoes on the screen that could be
confused with that of Karen Danielson, and the AIS information was also available. Therefore, the VTS-centre did not request Karen Danielson to report in at a given point within the radar coverage and the centre did not call the ship after the ship had appeared on the radar screen. Irrespective of the fact that the VTS-centre had no doubt about Karen Danielson’s identity on the radar screen, the investigators were of the opinion that, that
by omitting to request the ship to report and by omitting to call the ship, the centre
cut off themselves from direct contact with Karen Danielson’s master or the officer on
watch and hereby the positive effect such contact could have had to get the attention
of the person on watch. The investigators were of the opinion that the lack of proximity alarms prevented the inattentive operator on duty from being warned about the danger of
collision with the bridge.
The possibility for the VTS-centre to prevent the collision In order to prevent the collision, the VTS-centre should have followed Karen Danielson on the radar and realised that the ship was not turning as expected. If the VTS-centre had followed Karen
Danielson on the radar, the centre would only have had reason to assume that
something was wrong approximately 9 minutes before the collision occurred
because the ship did not turn east. The VTS-centre could have called Karen
Danielson on the VHF or sent out the guard vessel from Slipshavn.
The chief officer on Karen Danielson was alone on the bridge. It is not possible
to determine whether he would have heard a call on the VHF. He did not hear the
“line alarm” from the GPS navigation which sounded for about 10 minutes.
It would have taken approximately 10 minutes from the VTS-centre’s alarm for
the guard vessel to get close to Karen Danielson. This would have been too late
in this case. Even if the VTS operator had realised that Karen Danielson was not
turning east, it is doubtful whether it would have made any difference to the
collision. The Admiral Danish Fleet has stated that they have established the following special procedures for ships that are navigating from Svendborg into the VTS area:
· Svendborg Port informs VTS Great Belt by fax when a ship departs
· The VTS-centre calls the ships 5-10 minutes before they reach the turning point and asks them to confirm their intention to alter course.
The full report can be downloaded from:
www.soefartsstyrelsen.dk/sw8455.asp
Footnote: The hours culture applicable to seafarers!
Although no new crew members were involved in the incident the investigators noted a disturbing factor around how crew changes are now undertaken in total contravention of the Working Time Directive which results in ships’ personnel joining the vessel in an already extremely fatigued state. The report notes:
The 2nd officer together with four other new crew members joined the vessel around 1000 hours on 3 March 2005 after travelling by mini-bus from Split in Croatia to Svendborg, in Denmark. This was a direct drive of 26 hours, they were accompanied by two drivers and a crew manager from the manning agency. Upon arrival at the ship they went through their respective handovers and the departing crew members left to return to Croatia with the same mini-bus shortly after 1400 hours on 3 March. The joining crew went straight on duty upon arrival at the vessel.
Due to the busy work schedule planned for the 3rd March, all on board, both existing and newly joined crew worked throughout the day on the 3 March 2005.
I understand that this appalling disregard of the “Human Element” is apparently now common practice as a means of saving the cost of hotel bills and air fares.
JCB
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