CASE STUDIES

1. BP3IP - JAKARTA BRIDGE TEAM MANAGEMENT CASE STUDIES

2. BP3IP - JAKARTA BRIDGE TEAM MANAGEMENT ROYAL MAJESTY • Cruise ship with 1509 persons on board grounded on Rose and Crown Shoal off Nantucket Island on 10 June 1995. • No deaths or injuries, however damage to the vessel and lost revenues totaled $7 million. • Failure of Integrated Navigation System and Bridge Team Management caused vessel to stray 17 miles west of its intended Bermuda-Boston Track.

3. BP3IP - JAKARTA BRIDGE TEAM MANAGEMENT WHY USE CASE STUDIES? • “It will never happen to me” • Reinforce the basics of Navigation, and Bridge Team Management.

4. BP3IP - JAKARTA BRIDGE TEAM MANAGEMENT ILLUSTRATIVE CASE STUDY • At 1920 the Chief Officer identifies on radar a target in the position where the “BA” buoy should appear. Weather is clear, but sun is setting in the direction of the buoy. • At 1930 C/O notifies master that he has seen the ”BA” buoy ten minutes earlier. C/O did not tell master that buoy was not identified visually. • At 2000 the 2/M relieved the C/O on the Bridge. C/O did not tell of the circumstances of identifying the “BA” Buoy. • 2/M reduces the scale of the operating radar to 6 mile range. • 2/M plotted positions from the GPS only, did not look at the Loran. • At 2030 the port lookout report a yellow light. 2/M acknowledged but took no action. • Shortly after both lookouts reported high red lights off the port side. 2/M acknowledged but took no action. • At 2145 Master telephoned the bridge and asked the 2/M if he had sighted the “BB” buoy. He responded that he had. • At 2200 Master arrived on the bridge and again asked if the 2/M had sighted the “BB” buoy, and 2/M said yes.

5. BP3IP - JAKARTA BRIDGE TEAM MANAGEMENT • Master also checked the ARPA and its overlayed map, and confirmed the information from the 2/M. • 2/M Testified that he told the master he had seen the “BB” buoy even though he had not because he had “checked the GPS and was on track” and “perhaps the radar did not reflect the buoy” • 2/M also testified that on previous passages he had seen the buoy on radar and visually. • At 2210 the master left the bridge. A few minutes aft ward the port lookout reported “blue and white” water ahead. The 2/M acknowledged but took no action. • At 2220 the vessel veered unexpectedly to port, the sharply to starboard and heeled to port. 2/M put the vessel in hand steering. Master arrived on the bridge, ordered one of the quartermasters to take the helm, and put the radar back on the 12 mile scale. • Nantucket Island was less than 10 miles distant. He went to the chart room to verify the position and ordered hard right rudder. • Before the helmsman could respond the vessel grounded. • After several attempts the vessel was pulled free with the assistance of several tugs.

6. BP3IP - JAKARTA BRIDGE TEAM MANAGEMENT • Prior to departure navigating officer tested navigation equipment and reported it to be operating in “perfect” condition. • Watch standers plotted fixes from GPS only, and information matched autopilot information. Chief Officer stated that he compare the information to the LORAN C, and that it was similar.

7. BP3IP - JAKARTA BRIDGE TEAM MANAGEMENT

8. BP3IP - JAKARTA BRIDGE TEAM MANAGEMENT DISKUSI KELOMPOKANALISAKESIMPULAN

10. Analysis and Conclusions • Watch officers performance • Failure to notice invalid position information for 24 hours. • Chief Officer and Second Officer failure to realize vessel was off-track despite presence of several indicators. • Electronics Performance • GPS Antennae disconnected after departure from Bermuda. Watch officers testify not hearing or acknowledging any alarm. • Fathometer alarm set at 0 meters instead of normal 3 meters. • Identification of Navaids. Coincidence of passing a wreck buoy when the “BA” buoy was supposed to be sighted. Mistaken belief that everything was all right, and making the available information match what was expected.