New Zealand ferry operator fined $400 000 for failing to train crew to hold down a button for five seconds to disable autopilot and avoid running aground

From RNZ yesterday:

Maritime NZ says there was a clear knowledge gap in how a steering console worked aboard the Aratere ferry ahead of it running aground nearly two years ago. KiwiRail had been ordered to pay a fine of $375,000 and $25,000 costs after pleading guilty to charges under the Health and Safety at Work Act 2015 today.

The ship ran aground during a freight sailing from Picton to Wellington on 21 June 2024. No injuries were reported among the 39 crew and eight passengers aboard. Maritime NZ said an investigation found failures in KiwiRail’s change management processes for training and the documentation of changes to steering functions following upgrades ahead of the grounding.

Maritime NZ Director, Kirstie Hewlett, said crews must have a clear understanding of the workings of steering critical controls and how to override any automatic commands.

Source: https://www.msn.com/en-nz/news/national/crews-had-clear-knowledge-gap-on-aratere-ferry-ahead-of-grounding/ar-AA22kfTu?ocid=BingNewsVerp

When I read that last bit, I remembered this:

It’s been 20 years since the fatal crash involving the Queen of the North ferry, which ran aground on a voyage between Port Hardy and Prince Rupert in the early hours of March 22, 2006. Two of the 101 people on board — Gerald Foisey and Shirley Rosette of 100 Mile House — were presumed drowned, and their bodies remain missing two decades later. https://uk.news.yahoo.com/b-c-ferries-details-close-023441265.html

No CalMac ferry has ever run aground with the loss of lives.

What was the problem with overriding the automatic commends which were directing the NZ ferry onto the rocks?

Interislander ferry Aratere ran aground after a button was “inadvertently pressed”, sending the vessel off-course, according to an internal safety bulletin obtained by 1News. According to the bulletin, dated July 5, the bridge crew had switched the Aratere from hand steering to autopilot as it passed Mabel Island when an “execute button was inadvertently pressed” at 9.26pm.

This led the vessel to “commence an alteration of course” by around 1 nautical mile earlier than planned. The bridge team attempted to switch back to hand steering mode but was unable to override the autopilot in time.

Hewlett denied New Zealand First’s query as to whether the Aratere ran aground after someone onboard the vessel “put the autopilot on, went for a coffee, and then couldn’t turn the autopilot off” when they returned.

“While the cause of the grounding is yet to be formally determined, Maritime NZ’s preliminary enquiries have found that the incident was not due to a crew member leaving the bridge to make a coffee,” she said. https://www.1news.co.nz/2024/07/10/aratere-ran-aground-after-a-button-was-inadvertently-pressed/

See that ‘The bridge team attempted to switch back to hand steering mode but was unable to override the autopilot in time?’

What had they not been trained to do? From the official investigation report:

The bridge team was unaware that to transfer steering control from the autopilot to the central steering console, the new steering system required them to either set the same rudder command at both consoles, or hold down takeover button for five seconds. https://taic.org.nz/news/interim-factual-report-grounding-interislander-ferry-aratere

I often forget to do that when I’m resetting the dishwasher but only my temper is lost.


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