Report on the investigation of

the grounding of

CFL Performer
Haisborough Sand

North Sea

12 May 2008

Marine Accident Investigation Branch

Carlton House
Carlton Place
Southampton
United Kingdom
SO15 2DZ

Report No 21/2008
December 2008
 Extract from

The United Kingdom Merchant Shipping

(Accident Reporting and Investigation)

Regulations 2005 – Regulation 5:

“The sole objective of the investigation of an accident under the Merchant Shipping (Accident
Reporting and Investigation) Regulations 2005 shall be the prevention of future accidents
through the ascertainment of its causes and circumstances. It shall not be the purpose of an
investigation to determine liability nor, except so far as is necessary to achieve its objective, to
apportion blame.”

NOTE

This report is not written with litigation in mind and, pursuant to Regulation 13(9) of the
Merchant Shipping (Accident Reporting and Investigation) Regulations 2005, shall be
inadmissible in any judicial proceedings whose purpose, or one of whose purposes is to
attribute or apportion liability or blame.

Further printed copies can be obtained via our postal address, or alternatively by:
Email: maib@dft.gsi.gov.uk
Tel: 023 8039 5500
Fax: 023 8023 2459
All reports can also be found on our website:
www.maib.gov.uk
 CONTENTS
Page

SYNOPSIS 1

Section 1 - FACTUAL INFORMATION 3

1.1 Particulars of CFL Performer and accident 3
1.2 Narrative 4
1.2.1 The grounding 4
1.3 Action in Grimsby 7
1.3.1 The vessel 7
1.3.2 Port State Control 7
1.3.3 Additional International Safety Management (ISM) audit 8
1.4 Crew 8
1.5 Amendment to the voyage plan 8
1.6 ECDIS - FURUNO FEA-2107 9
1.6.1 Installation 9
1.6.2 Operation 10
1.6.3 Contours and depths 10
1.6.4 Route planning 11
1.6.5 Route monitoring 11
1.6.6 Security 12
1.7 Equipment familiarity 12
1.8 ECDIS data 12
1.8.1 Examination 12
1.8.2 Display at the time of the grounding 14
1.9 Safety management 15
1.9.1 Vessel management 15
1.9.2 Onboard procedures 15
1.10 ECDIS requirements 15
1.10.1 Carriage 15
1.10.2 Training 16
1.10.3 Performance standards 17
1.10.4 Conformance with IMO performance standard 17
1.11 Voyage planning requirements 17
1.12 Similar accidents 18

Section 2 - ANALYSIS 19
2.1 Aim 19
2.2 Passage plan 19
2.3 Use of ECDIS 21
2.3.1 Training and familiarity 21
2.3.2 IMO model course 22
2.3.3 Equipment-specific training 22
2.4 Route monitoring 22
2.5 Watch vector 23
2.6 Safety management 23
Section 3 - CONCLUSIONS 25
3.1 Safety issues 25
3.1.1 Safety issues directly contributing to the accident which have
resulted in recommendations 25
3.1.2 Other safety issues identified during the investigation also
leading to recommendations 25
3.1.3 Safety issues identified during the investigation which have
not resulted in recommendations but have been addressed 26

Section 4 - action taken 27

4.1 Vertom Scheepvaart & Handelmaatschappij B.V. 27
4.2 CFL Shipmanagement B.V. 27
4.3 FURUNO (European Branch Office) 27

Section 5 - recommendations 28

Figure 1 Vessel’s track recorded by AIS

Figure 2 ECDIS display at 1:100000 scale

Figure 3 ECDIS display at 1:50000 scale

Figure 4 Vessel’s AIS track over Haisborough Sand

Figure 5 Extract of the original passage plan

Figure 6 Screen shot of the ECDIS display showing depth and contour
settings (taken at the Furuno European Branch Office)

Figure 7 Screen shot showing title of original plan

Figure 8 Screen shot showing safety contour set in original plan

Figure 9 Screen shot showing alarm log

Figure 10 Vessel’s original and revised planned routes

Figure 11 Screen shot showing display with 0 metre safety depth set
(taken at the Furuno European Branch Office)

Annex A Extract of Furuno FEA-2107 ECDIS Operations Manual

Annex B Circular letter NTD 1/2008

Annex C Circular letter NTD 12/2008

Annex D Circular sent by Canada Feeder Lines BV

GLOSSARY OF ABBREVIATIONS AND ACRONYMS

AIS - Automatic Identification System

AMETIAP - Association of Maritime Educational and Training Institutions

Asia-Pacific Regions
BSH - Bundesamt Für Seeschifffahrt Und Hydrographie

CEC - Certificate of Equivalent Competency

CFL - Canada Feeder Lines

CIRM - Comité International Radio- Maritime (The International

Association for Marine Electronics Companies)
DOC - Document of Compliance

DPA - Designated person ashore

ECDIS - Electronic Chart Display Information System

ENC - Electronic Navigational Chart

ETA - Estimated Time of Arrival

EU - European Union

EUT - Equipment Under Test

GPS - Global Positioning System

GT - Gross tonnage

HSC - High Speed Craft

IAMI - International Association of Maritime Institutions

ICS - International Chamber of Shipping

IEC - International Electrotechnical Commission

IMO - International Maritime Organization

ISM Code - International Management Code for the Safe Operation of

Ships and for Pollution Prevention

kts - knots

kW - kilowatt
m - metre

MCA - Maritime and Coastguard Agency

MT - Metric Tonne
NAABSA - Not Always Afloat But Safely Aground
nm - nautical miles
OOW - Officer of the watch

PSC - Port State Control

RPM - Revolutions per minute

SENC - System Electronic Navigational Chart

SMS - Safety Management System

SOLAS - International Convention for the Safety of Life at Sea

STCW - International Convention on Standards of Training, Certification

and Watchkeeping Incorporating the 1995 Amendments
TSS - Traffic Separation Scheme

UPS - Uninterrupted power supply

UTC - Universal Co-ordinated Time

VDR - Voyage Data Recorder

 Times: All times used in this report are UTC +2 unless otherwise stated
 SYNOPSIS
At 1619 on 12 May 2008, the Netherlands registered dry cargo
ship, CFL Performer, ran aground on Haisborough Sand off the
east coast of England. The vessel was refloated 15 minutes
later and continued on passage to Grimsby, River Humber,
where she arrived the following morning. There were no injuries
or damage to the vessel, and there was no pollution.

The grounding occurred when CFL Performer was on passage

from Paramaribo, Suriname. The ship was carrying 6020 MT
of bauxite, and grounded 29 minutes after the OOW had adjusted course to follow
the passage plan shown on the vessel’s Electronic Chart Display Information System
(ECDIS). The planned route took the vessel across Haisborough Sand, where the
charted depth of water was considerably less than the vessel’s draught. It is clear that
this route was not adequately checked for navigational hazards either when planned
or when being monitored.

ECDIS was the primary means of navigation, but none of the vessel’s bridge
watchkeeping officers had been trained in its use. Consequently, many of the
system’s features which could have prevented this accident were not utilised. Similar
factors have been contributory to a number of recent groundings in UK waters.
Although the use of ECDIS as the primary means of navigation is set to increase
markedly during the next 10 years, specific competences in its operation have not yet
been included in the STCW Code.

A recommendation has been made to the Maritime and Coastguard Agency (MCA)
to support a proposal under consideration by the International Maritime Organization
(IMO) for the inclusion of ECDIS competences within the STCW Code, and to press
for the training required to meet such competences to be fit for purpose and assessed
by examination and performance. Further recommendations have been made to
the International Chamber of Shipping (ICS), the International Association of Marine
Institutes (IAMI), the Association of Marine Educational and Training Institutes Asia-
Pacific Regions (AMETIAP) and the International Association for Marine Electronics
Companies (CIRM) aimed at improving the quality and effectiveness of both generic
and equipment specific training in ECDIS. A recommendation has also been
made to the International Chamber of Shipping to promote the need to preserve
recorded information, including ECDIS information, following an accident. A further
recommendation has been made to CFL Shipmanagement B.V. which seeks to ensure
procedures are incorporated into its safety management system on the use of ECDIS.

1
 Reproduced courtesy of FotoFlite

2
CFL Performer
Section 1 - FACTUAL INFORMATION
1.1 Particulars of CFL Performer and accident
Vessel details

Registered owner : Canada Feeder Lines B.V.

Technical manager : Vertom Scheepvaart- & Handelmaatschappij B.V.

Port of registry : Groningen

Flag : Netherlands

Type : General cargo

Built : 2007 Holland

Classification society : Lloyd’s Register

Construction : Steel

Length overall : 118.4m

Gross tonnage : 4106

Engine power and/or : Wartsila 6426A2, 2040kW at 221 RPM

type

Propulsion : Single screw controllable pitch propeller

Service speed : 12 knots

Other relevant : The vessel’s charter party contained a NAABSA

information clause
Maximum Summer draught 6.09m

Accident details

Time and date : 1619 on 12 May 2008

Location of incident : 52º 54.123’ N, 001º 43.695’ E

Persons on board : 8

Injuries/fatalities : None

Damage : None

3
1.2 Narrative
1.2.1 The grounding
On 26 April 2008, CFL Performer sailed from Paramaribo, Suriname bound for
Grimsby, UK, carrying 6020 MT of Bauxite. Her estimated time of arrival (ETA) at
the entrance to the River Humber was midnight on 12 May.

The vessel transited the Dover Strait Traffic Separation Scheme (TSS) on the
evening of 11 May, and during the 1200-1600 watch the following day, the second
officer was the officer of the watch (OOW). The vessel’s position was monitored in
relation to the voyage plan using the vessel’s Electronic Chart Display Information
System (ECDIS)1. To follow the plan, the vessel’s course was adjusted at 1403
from 356º to 321º and again at 1550 to 331º (Figure 1). The vessel was in
autopilot and her speed over the ground was about 9.5 knots.

AIS data courtesy of the MCA Figure 1

33
1°

1550
32
1°

1403
356°

Vessel’s track recorded by AIS

1 Electronic chart display and information system (ECDIS) means a navigation information
system which, with adequate back-up arrangements, can be accepted as complying with the up-to-
date chart required by regulation V/19 and V/27 of the 1974 SOLAS Convention, as amended, by
displaying selected information from a system electronic navigational chart (SENC) with positional
information from navigation sensors to assist the mariner in route planning and route monitoring,
and by displaying additional navigation-related information. (IMO Resolution MSC 232 (82))

4
The weather was fine; visibility was 6nm, the sea was calm and the wind was
north-easterly between force 2 and 3. The tidal stream was south-easterly at
1 knot, and the predicted height of tide was about 2.5m (based on Cromer,
England). Both of the vessel’s radars were operating with the displays set at
the 6 miles and 12 miles range scales. During the watch, the second officer
prepared files for security and safety management audits which had been
arranged to take place during the vessel’s stay in Grimsby. He also completed
the passage plan from the pilot embarkation point to the anticipated berth.

At 1615 the second officer contacted the chief officer, who had not arrived on
the bridge at 1600 as expected. Shortly afterwards, the master, who was in his
cabin, felt a change in the vessel’s vibrations. He called the second officer and
instructed him to check the depth of water. The second officer looked at the
ECDIS display and reported to the master that there was no cause for concern.
The depth sounder was not switched on.

The vibrations increased and the vessel began to slow down. At 1617 the
vessel speed was 6.9 knots, and by 1619 it had reduced to 1.1 knots. The
second officer realised that something was wrong and put the propeller pitch
to zero. He then changed the ECDIS display to a 1:50000 scale and saw that
the charted water depth was less than the vessel’s draught (Figures 2 and 3).
He realised that the vessel was aground on the Haisborough Sand2. This was
confirmed when the depth sounder was switched on.

The reduction in the vessel’s speed was detected by Yarmouth coastguard

using the Automatic Identification System (AIS) (Figure 4). At 1634, the
coastguard station called CFL Performer on VHF radio to establish if the vessel
was aground and needed assistance. The master, who had quickly made his
way to the bridge with the chief officer, informed the coastguard that the vessel
was aground but did not require assistance. He then put the propeller pitch to
full astern, and the vessel refloated without difficulty. The chief officer checked
the soundings of the double bottom tanks and the chief engineer checked the
temperatures of main and auxiliary machinery; no problems were found.

2Admiralty sailing Directions (NP54) states: (Haisborough Sand)… is 10 miles long and 1 mile
wide lying parallel to the Norfolk coast. It is marked to the NW by N Haisbro’ Light-buoy
(N cardinal), to the SE by S Haisbro’ Light-buoy (S Cardinal) and to the west by Mid Haisbro’
Light-buoy (starboard hand). The shoal has three drying patches (1995) close NE, E and ESE
of the Mid Haisbro’ Light-buoy. Except at slack water their positions are indicated by tidal eddies
and even a slight sea or moderate swell breaks on the shallower parts of the shoal. There are
a number of foul patches on the S part of the shoal. There are strong eddies on and around the
bank, especially to the NW.

5
 Figure 2

ECDIS display at 1:100000 scale

Figure 3

ECDIS display at 1:50000 scale

6
 AIS data courtesy of the MCA Figure 4

1619
1.1 kts
1617
6.9 kts
1615
9.3 kts

1609
10.9 kts

Vessel’s AIS track over Haisborough Sand

1.3 Action in Grimsby

1.3.1 The vessel
CFL Performer berthed at Grimsby at 0052 on 13 May. The master informed
Lloyd’s Register, the vessel’s classification society, of the grounding at midday,
and the vessel’s designated person ashore (DPA) at 1445. No action was taken
to save the information recorded on the vessel’s voyage data recorder (VDR).

1.3.2 Port State Control

The Maritime and Coastguard Agency (MCA) carried out a Port State Control
(PSC) inspection on board CFL Performer and detained the vessel for the
following deficiencies:
• The routing of the vessel with a draught of 5.9m across Haisborough
Sand where the charted depth was less than 2m.
• The ship’s navigating officers not being trained in the use of ECDIS.
• Not reporting the incident to the vessel’s DPA for 23 hours.
• The chart support certificate had expired.
• A Netherlands Certificate of Equivalent Competency (CEC) for the
second officer was not made available for inspection.
• A cadet was being used as a rating watchkeeper (lookout) without rating
watchkeeper certification.

7
1.3.3 Additional International Safety Management (ISM) audit3
Following the vessel’s detention, the Netherlands administration instructed Lloyd’s
Register to conduct an ‘additional’ ISM audit on board the vessel. The audit
identified two major non conformities: the first related to the failure of the master
to report the grounding to the DPA for 23 hours, and the second to the navigating
officers’ lack of familiarity with, and incorrect use of, the ECDIS system on board.

1.4 Crew
The crew comprised the master, chief officer, second officer, chief engineer, two
deck ratings, a cook and a deck cadet. All the officers held appropriate STCW
certificates of competency obtained from their respective countries of origin, and
CECs for working on a Netherlands registered vessel. None of the crew had
previously been employed by Canada Feeder Lines (CFL).

The master had been at sea for 22 years, and held a deep sea captain’s
certificate issued by the Ukrainian administration. He had been employed as a
master since February 2007 and had served on two other ships in this rank. He
joined CFL Performer in February 2008, and kept the 8-12 bridge watches.

The chief officer held a Ukrainian licence and had 6 years’ experience at sea. He
joined CFL Performer as second officer in March 2008 and was promoted to chief
officer on 25 April 2008. The chief officer kept the 4-8 bridge watches.

The second officer’s certificate of competency was issued by the Philippines

administration in January 2002. He first went to sea in 1979 and had been a
second officer for 16 years. He joined CFL Performer on 24 April 2008, and kept
the 12-4 bridge watches.

1.5 Amendment to the voyage plan

The voyage from Paramaribo to Grimsby was planned on the ECDIS by the chief
officer before he was promoted. The plan was named Paramaribo-Grimsby and
an extract is at Figure 5.

At about 2100 on 11 May 2008, the master called the chief officer to the bridge
and instructed him to amend the passage plan to enable CFL Performer to arrive
at the Humber pilot station 1 hour sooner than her existing Estimated Time of
Arrival (ETA). This was to ensure that the vessel did not miss the high water
which would have delayed her berthing. Accordingly, the chief officer created
a new passage plan in the ECDIS using the scale of 1:100,000. The master
assisted in the selection of the revised waypoints, and the chief officer visually

3 An additional ISM audit may be carried out for the purpose of confirming DOC or SMC validity if
major nonconformities have been disclosed, significant changes have been introduced to
Company’s SMS or when the lead auditor finds that the number of nonconformities disclosed in the
Company’s/ship system during the last audit proves that such audit is necessary. Additional audits
may also be considered necessary when technical deficiencies and/or nonconformities are
discovered during onboard inspections and surveys.

8
 checked each leg of the new plan to ensure they were clear of hazards. In
doing so, he noticed that the vessel would leave a green conical buoy to port
in the vicinity of Haisborough Sand, but did not investigate further. The new
voyage plan took about 5 minutes to complete, and was in use when the second
officer took over the bridge watch at 1200 on 11 May 2008.

Reproduced from Admiralty Chart BA 1408 by permission of

the Controller of HMSO and the UK Hydrographic Office. Figure 5

Extract of the original passage plan

1.6 ECDIS - FURUNO FEA-2107

1.6.1 Installation
The ECDIS on board CFL Performer was a Furuno FEA-2107 which was
installed and commissioned by Radio Holland4 on 18 November 2007. Two
systems were fitted, with one system designated as the master unit and the
second as the standby or slave unit. Radar, Global Position System (GPS),
AIS, gyro and speed log were connected through a local area network and
each ECDIS had its own Uninterrupted Power Supply (UPS). To facilitate a
seamless transition between systems in the event of a system failure, settings
and changes to one system were simultaneously duplicated in the other. As
two ECDIS systems were fitted, and used official Electronic Navigational Charts

4 Radio Holland (Rotterdam) is a service agent of FURUNO which specialises in the supply,

installation, integration and service of maritime electronics.

9
 (ENC)5, paper charts were not required to be carried. The vessel was provided
with an ECDIS operations manual, which was over 600 pages in length.
Extracts of the manual are shown at Annex A.

1.6.2 Operation
The FEA 2107 chiefly operates in two modes: planning and monitoring. Changes
to an existing passage plan input in the system can only be carried out by
accessing the plan concerned and ticking a box titled Enable changes. The
system does not allow the alteration of a plan when it is in the monitoring mode.
Although it is possible to monitor one plan and edit another on the same screen,
it was the usual practice on board CFL Performer to plan on the slave system
display and to monitor the route in use on the main system display.

The system can display ENCs at different scales, with the degree of detail
displayed increasing or reducing in line with the scale selected. The FEA-
2107 indicates when chart information on a larger scale than the one in use is
available, or when the scale selected is larger than the optimum scale available.

1.6.3 Contours and depths

A number of settings related to the charted depth are applied on the ECDIS:
the safety contour, the safety depth and the shallow and deep contours. The
safety contour provides a visible boundary between “safe” and “unsafe”
water with respect to depth, and is highlighted on the display to enable easy
identification. It is selected by the navigator to reflect a ship’s draught, adjusted
for the required under keel clearance and for the height of tide, if required. As
depth contours on an ENC are normally only drawn at 5m intervals, the system
automatically uses the deeper contour when the selected safety contour depth
lies between contours.

The safety depth applies to spot soundings, the depth of which is insufficient
for a vessel to safely pass over. Spot soundings less than the safety depth are
displayed in bold type to provide a more accurate representation of a vessel’s
‘no-go’ line than the safety contour (Figure 6).

The shallow and deep contours are utilised when the multi-colour depth display
is selected. The deep contour is normally set at twice a vessel’s draught to
indicate when squat is likely to be experienced. The area between the 0m
contour and the shallow contour is coloured dark blue, the area between the
shallow and safety contour is coloured light blue, and the area between the
safety contour and the deep contour is coloured grey. This allows the gradient
of the seabed to be graphically displayed. All of the area between the 0m
contour and the safety contour is also hatched (Figures 2, 3 and 6).

5 An ENC database stores chart information within an ECDIS in the form of geographic objects

represented as unique vectors. A System Electronic Navigational Chart (SENC) is a database

resulting from the transformation of an ENC by ECDIS for use by the mariner.

10
 ECDIS data courtesy of Furuno
European Branch Office Figure 6

Depth

Safety contour 30m

Safety depth 6m

Screen shot of ECDIS display showing depth and contour settings

(taken at the Furuno European Branch Office)
1.6.4 Route planning
When route planning, the ECDIS calculates chart alarms using user defined off
track or channel limits for the route selected. Danger areas within the channel
limits are shaded red if the safety contour or selected danger areas are crossed
(Figure 6). The default setting for the channel limit is 185m either side of a
planned track, and the default setting for the safety contour alarm is 30m. Once
a plan has been completed, it can be verified using the system’s ‘check page’,
which helps the user to identify legs of a plan where the safety contour has
been crossed and where defined danger areas are located. A plan does not
have to be free of warnings or alarms to allow it to be saved and monitored.

1.6.5 Route monitoring

Route monitoring is divided into two categories: monitored route, and predicted
movement. In the first category, an audible alarm activates to warn the user
when a vessel moves outside the channel limits and when nearing a waypoint.
In the second, an audible alarm sounds when a ship is going to cross the safety
contour set on the display, which can differ from the safety contour alarm setting
used when planning. To enable this alarm, a watch vector (time and angle)
must be defined by the user (Annex A). If a watch vector is not defined, the

11
 safety contour alarm will not activate. When an un-checked plan is monitored,
the name of the plan at the top of the ECDIS screen is displayed in red, as are
the areas within the channel limits where the safety contour is crossed (Figure
6).

1.6.6 Security
Fixed vessel parameters were entered into the system at installation. A floppy
disc provided by the manufacturer was needed to access and change these
parameters. However, a WindowsTM interface was accessible via an external
keyboard which did not require the user to provide security discs or passwords,
and through which system files could be accessed.

1.7 Equipment familiarity

In November 2007, Radio Holland conducted ECDIS training on board CFL
Performer for the master, chief officer and second officer who were in post at
the time. The training occurred before the vessel entered service, and was
specific to the Furuno ECDIS. The training consisted of two sessions, each
lasting between 4 and 5 hours. No training in the use of ECDIS was provided
for officers who subsequently joined the vessel.

Of the officers on board at the time of the grounding, neither the chief officer
nor the second officer was trained in the operation of ECDIS, but both had used
such equipment on previous ships. The master had no previous experience
or training on ECDIS or any other form of electronic navigation system. None
of the officers were aware of the significance of the safety contour, the safety
depth, and the shallow and deep contours, and did not know how to establish
a watch vector ahead of the vessel, or its significance. They also did not know
how to use the ‘check page’ (Annex A) to ensure that all course lines and
associated channel limits were clear of navigational dangers.

At the time of the grounding, the vessel’s owner was in the process of obtaining
feedback from its ships’ officers regarding their experience with ECDIS, with a
view to identifying future training needs.

1.8 ECDIS data

1.8.1 Examination
Immediately following the grounding, the MAIB conducted a detailed examination
of the vessel’s ECDIS. The key findings were:
• The voyage plan in use at the time of the grounding had been deleted.
• The original passage plan from Paramaribo to Grimsby was saved as a file
called “Paramaribo-Grimsby”. The plan was created on 14 April and was last
modified on 2 May. The title of the plan and the tracks were coloured red on
the display (Figure 7).
• The safety contour used on the original passage plan was 30m (Figure 8).

12
 Figure 7

Screen shot showing title of original plan

Figure 8

Screen shot showing safety contour set in original plan

13
 • The waypoint approach alarm activated immediately prior to the vessel’s
course alterations at 1403 and 1550 on 12 May 2008 (Figures 1 and 9).
• The safety contour alarm did not activate at any time during the voyage
(Figure 9).
• The voyage log file did not record the name of the passage plan in use, but
contained sufficient information to reconstruct the vessel’s track.
• The chart usage file was deleted.
• All of the charts required for the vessel’s passage to Grimsby were official
ENCs.
Figure 9

Screen shot showing alarm log

The ECDIS was also examined on 29 June 2008. On this occasion, the voyage
log was found to have been reset. This deleted the information recorded during
the vessel’s voyage to Grimsby.

1.8.2 Display at the time of the grounding

The scale selected was 1:100,000, which was the scale in use when the second
officer relieved the master at 1200. The name of the plan and the intended
track were displayed in red, and the channel limit was set to 185m. No watch

14
 vector was set. Display settings for the safety, shallow and deep contours
or the safety depth were not recorded, but the safety contour selected was
reported to be 30m.

1.9 Safety management

1.9.1 Vessel management
CFL Performer was the second of a series of nine new sister ships administered
by CFL on behalf of their owners. Established in 2007, the company employed
two staff and contracted responsibility for the vessels’ technical and safety
management to Vertom Scheepvaart & Handelmaatschappij B.V., a well
established ship manager which held an ISM Document of Compliance (DOC)
and provided a Designated Person Ashore (DPA) for CFL’s vessels. The
responsibility for the implementation of the vessels’ safety management system
was, in turn, subcontracted to Q- shipping. CFL engaged the services of Global
Crew Management B.V. to provide the crew for its vessels. At the time of the
publication of this report, CFL administered five vessels in service, with a further
eight on order.

1.9.2 Onboard procedures

An interim ISM audit was conducted by Lloyd’s Register on behalf of the
Netherlands administration before CFL Performer entered service on
19 November 2007. Under the heading of Chart Corrections & Nautical
Publications, the audit report noted the vessel’s exemption from carrying paper
charts. The SMS on board CFL Performer did not contain any reference to
ECDIS or any instructions regarding the use of the VDR.

Shortly before the grounding, CFL issued a questionnaire to its fleet of three
ships in service to gain feedback on the use of ECDIS. There was no written
policy regarding the length of handover between officers leaving and joining CFL
vessels.

1.10 ECDIS requirements

1.10.1 Carriage
Carriage of ECDIS will be mandatory on High Speed Craft (HSC) built after
2008, and existing HSC are to be retrofitted by 2010. Proposed amendments to
SOLAS, Chapter V Safety of Navigation, Regulation 19 Carriage requirements
for shipborne navigational systems and equipment require the mandatory
carriage of ECDIS on new passenger vessels of 500GT and above, and new
tankers and cargo ships of 3000GT and above starting 2012 and proceeding in
phases over the following 2 years. The proposal also requires existing ships to
be retrofitted with ECDIS by 2018.

15
1.10.2 Training
Although Table A II/1 of the STCW95 Convention states that ECDIS systems
are considered to be included under the term “charts”, there is no mandatory
international requirement for navigating officers to undertake specific ECDIS
training, and the requirements of individual national administrations differ in
this respect. The UK administration includes ECDIS in its syllabus for all
deck officers, and also requires navigating officers to receive both generic
and equipment-specific training when serving on vessels fitted with ECDIS.
However, most other European Union (EU) administrations, including the
Netherlands, rely on the general requirements placed upon ship owners
and managers by the ISM Code to ensure all personnel are familiar with the
equipment they are expected to use. The Code states:
The Company should establish procedures to ensure that new personnel
and personnel transferred to new assignments related to safety and
protection of the environment are given proper familiarization with their
duties

Guidelines have been issued to surveyors conducting PSC inspections under

the Paris Memorandum of Understanding, which includes:
Are the master and deck watchkeeping officers able to produce
appropriate documentation that generic and type specific ECDIS
familiarisation has been undertaken?

In September 2008, an ad hoc intersessional working group of the IMO Sub-

Committee on Standards of Training and Watchkeeping (STW) considered a
proposal submitted by Australia to include additional competences related to
the knowledge and use of ECDIS in tables A-II/1, A-II/2, A-II/3 and section B-II/1
of the STCW Code. The proposed amendments include the demonstration of
competence by the examination and assessment of evidence from approved
training ship experience, approved ECDIS simulator training, and approved
in-service experience. The proposal was supported by the United Kingdom,
and will be further considered at the next meeting of the STW sub-committee
scheduled for February 2009.

The framework of an ECDIS course, titled “Model Training Course on the

Operational Use of ECDIS” (Model Course 1.27) was published by the
International Maritime Organization (IMO) in 2000, and provides detailed
guidance on content, the facilities required, basic entry level qualifications,
certification, and simulator exercises. Many ECDIS training courses based
on the IMO model course are run by maritime training colleges and other
educational organisations around the world. The course is designed for
40 hours of instruction (1 week), and successful completion is dependent
on attendance. Although tests and evaluations are suggested, there is no
requirement for attendees to pass an examination.

16
1.10.3 Performance standards
The performance specification for ECDIS was originally detailed in 1995 in IMO
Resolution A.817(19) and was amended by:
• Resolution MSC.64(67) - Adoption of New and Amended Performance
Standards- Annex 5, which was adopted on 4 December 1996;
• Resolution MSC.86(70) – Adoption of New and Amended Performance
Standards for Navigational Equipment, Annex 4, which was adopted on 8
December 1998; and
• Resolution MSC.232(82) – Adoption of the Revised Performance
Standards for Electronic Chart Display and Information System (ECDIS),
which was adopted on 5 December 2006.

The ECDIS performance standard does not stipulate specific requirements for
the system interface or terminology, and many of the available approved ECDIS’
differ in terms of their user menus, hardware interfaces and nomenclatures.

The requirements of the performance standard include:

4.10.5.3 ECDIS shall give an alarm if the ship, within a specified time set
by the mariner, is going to cross the safety contour.
10.6.3 It should not be possible to manipulate or change the recorded
information

1.10.4 Conformance with IMO performance standard

The type approval for the FURUNO ECDIS was carried out by Bundesamt Für
Seeschifffahrt Und Hydrographie (BSH) in Germany. The type approval process
ensures that the IMO performance standards are met by testing against the
International Electrotechnical Commission (IEC) standard 61174.

1.11 Voyage planning requirements

SOLAS V regulation 34 requires the masters of all vessels which proceed to
sea to ensure that the intended voyage has been planned using the appropriate
nautical charts and publications, and to ensure the guidelines issued by IMO
in Annex 25 to Resolution A.893(21) are followed. Additional guidance is also
provided in SOLAS V Annex 24, which should be used in conjunction with the
IMO guidelines. The principles of voyage planning include:
• Intended tracks and course alteration points, along with areas of danger,
should be marked on the navigational charts, taking into account the
margins of allowable error and minimum under-keel clearance.
• Everyone who is concerned with the vessel should be comprehensively
briefed.

17
 • The vessel’s position is closely and continuously monitored, and is cross-
checked using different methods; reliance on a single method of position
fixing should be avoided.
• The decisions of individuals are cross-checked so that errors can be
detected.

1.12 Similar accidents

The MAIB is aware of a number of accidents in recent years in which the use
or misuse of ECDIS or ECS has been identified as a contributing factor. In
August 2004, a cross channel ferry grounded after the helm was put the wrong
way as the vessel approached a port entrance. This mistake was not noticed
by the bridge team and, although an ECDIS was in use, no warning was given
to indicate that the vessel was approaching shallow water because the watch
vector or predicted movement warning area had not been correctly enabled.

In 2006, a ro-ro ferry ran aground after the safety contour in her ECDIS was
set at 30m. This caused the chart display to be shaded blue, which severely
impeded the bridge team’s ability to see that the vessel was outside the
navigable channel.

In January 2008, a ro-ro passenger ferry hit a submerged wreck near Dover
and severely damaged her propellers. Although the vessel’s primary means
of navigation was paper charts, her deck officers relied on the vessel’s ECS,
despite not having been trained in its use. The wreck was not shown on the
ECS display due to the settings applied to the system at the time.

Contributory factors to the grounding of a container ship in UK waters early

in 2008 included the lack of training in the use of the vessel’s electronic chart
system. This resulted in the use of inappropriate settings with regard to depth
contours, and chart and depth alarms.

18
Section 2 - ANALYSIS
2.1 Aim
The purpose of the analysis is to determine the contributory causes and
circumstances of the accident as a basis for making recommendations to prevent
similar accidents occurring in the future.

2.2 Passage plan

The passage plan in use when CFL Performer grounded could not be retrieved
from the ECDIS. However, as the activation of the waypoint approach alarms
(Figure 9) corresponds to the vessel’s positions transmitted by AIS (Figure 1),
the vessel’s AIS track is considered to be representative of the intended passage.
The alteration of course to 331º at about 1550, which took the vessel across
Haisborough Sand towards the vessel’s original planned track (Figure 10), was
therefore made to follow the planned route shown on the ECDIS display. In
view of the fact that the depth of water over the majority of Haisborough Sand
was significantly less than 5m, it was inevitable that CFL Performer, which had a
draught of about 6m, would run aground.

Reproduced from Admiralty Chart BA 1408 by permission of

the Controller of HMSO and the UK Hydrographic Office. Figure 10

Projected track 13:48

12:01

Original
passage plan
AIS / revised track

10:40

Vessel’s original and revised planned routes

19
 The route was planned and executed on the vessel’s ECDIS, which had
numerous in-built safeguards intended to prevent an accident of this nature.
However, it is evident that on this occasion these safeguards were not utilised,
and system warnings were not acted upon, either when the route was planned
or when it was monitored. In particular:
• The system’s check page was not used to check each leg of the route for
navigational hazards.
• The plan was executed despite its title remaining red, indicating that the
intended route crossed the safety contour set or other defined dangers.
• The safety contour alarm did not sound as the vessel approached the
shallow because a watch vector had not been set.

It is also highly likely that the configuration of the display was not optimised to
make the presence of the shallows over Haisborough Sand readily apparent.
At a scale of 1:100000 and with a safety contour of 30m selected (Figure 2),
the shallows over the bank are much harder to identify than when viewed at a
scale of 1:50000 (Figure 3). Furthermore, the identification of the depths over
Haisborough Sand would have also been highly dependent on the safety depth
selected (Figures 6 and 11). However, although the configuration of the display
ECDIS data courtesy of Furuno
European Branch Office Figure 11

Screen shot showing display with 0 metres safety depth set

(taken at the Furuno European Branch Office)

20
 would have affected the officers’ ability to see the shallows, the drying patches
in the vicinity of the Mid Haisbro’ buoy would have been visible regardless of
the settings applied. As these were not seen when the route was planned,
and as the vessel’s intended track would have passed over dark blue shading
and the diamond hatched markings, which are similar to the conventions used
for marking shallows and ‘no-go’ areas on paper charts, it is evident that the
planner’s visual check was only cursory. It is also evident that the amended
route was not cross-checked by the master.

2.3 Use of ECDIS

2.3.1 Training and familiarity
Route planning and monitoring are critical to the safe operation of every
vessel, and it is essential that requirements of SOLAS V are met, regardless of
whether ECDIS or paper charts are used. However, the differences between
the two media are considerable. This has been recognised by the International
Chamber of Shipping (ICS) in its Bridge Procedures Guide, which states:
Navigation with ECDIS is fundamentally different from navigating with
paper charts. As a consequence, the safe use of ECDIS requires the
mariner to be appropriately trained and appropriate bridge procedures
to be established

While the information shown on a paper chart is fixed, the electronic data within
ECDIS can be displayed and used in a variety of ways, which requires both
careful consideration and manipulation. This can be daunting and confusing
to untrained users. On this occasion, although the vessel’s deck officers were
trained in, and had experience in the use of paper charts, none had been
trained in the use of ECDIS. Consequently, they were ignorant of many of the
system requirements and features, and operated the system in a very basic and
inherently dangerous manner.

The use of ECDIS has steadily increased in recent years, and it is disturbing
that the number of accidents resulting from the incorrect use of ECDIS and
ECS through poor system knowledge has also risen (Paragraph 1.12). ECDIS
will soon replace paper charts as the primary planning and monitoring media
on board most vessels, but the system can only realise its potential benefits to
maritime safety if all mariners who are expected to use the equipment at sea
are properly trained. Therefore, the need for mandatory training in ECDIS is
compelling. Given the sophistication of the systems, and their differences in
terms of user menus, hardware interfaces and terminology, this can only be
achieved through both generic and equipment specific training. Reliance on
the requirements of flag states, knowledge of paper charts, on the job training
and self-tuition are not realistic or sensible options for such a vital piece of
navigational equipment.

21
 Consequently, the proposed inclusion of specific ECDIS competences within
the STCW Code is a very positive step, which merits strong support and early
adoption by IMO.

2.3.2 IMO model course

Generic training in the use of ECDIS is already available through the IMO
model course and, in view of the system’s proliferation over the next 10 years,
it would appear compelling that all bridge watchkeeping officers of vessels
on which ECDIS is the primary navigation system, complete this course. It is
also reasonable for the successful completion of the course to be determined
by practical assessment and examination, not just by attendance. However,
although the structure and syllabus of the course provides a benchmark for
training establishments, it is 8 years since the course was developed, and a
review of its content may be beneficial to take into account the experience
gained in the use of the system over that period, the lessons learned from this
and similar accidents, and to ensure the course still meets the requirements of
the maritime industry.

2.3.3 Equipment-specific training

The chief and second officers on board CFL Performer had used an ECDIS
on previous ships. However, the factors listed in Paragraph 2.2 indicate that
neither had an acceptable working knowledge of the operation of the Furuno
FEA-2107. Although ECDIS’ must meet the specific performance standards set
by the IMO, manufacturers inevitably vary aspects of equipment operation in
order to remain commercially competitive. This has led to differences between
systems in terms of menus, terminology and equipment interface. Such
differences can be marked and, although operations manuals are provided,
these are not always easily understood. A mariner’s proficiency in the use of
a particular system is therefore undoubtedly best served by the provision of
equipment-specific training, regardless of any previous training and experience.

2.4 Route monitoring

During the afternoon of 12 May, the OOW relied on ECDIS alarms to warn when
the vessel was approaching an alteration of course or was more than 185m
off the intended track. In effect, the monitoring of the vessel’s progress was
undertaken by the ECDIS, while the OOW spent much of his watch preparing
for forthcoming audits and passage planning.

The second officer presumed that the vessel would be safe providing she
remained within the channel. Consequently, he paid little attention to where
the vessel was heading, and did not: investigate the significance of the South
Haisbro’ cardinal mark and the Mid Haisbro’ starboard conical buoy, which
the vessel passed at a distance of about 1 mile; check the new course before
altering at 1550; see the eddies or disturbed water which, given the height of
tide, were probably visible directly ahead of the vessel before she grounded,

22
 or; ensure that the echo sounder was switched on, particularly when the master
raised concern regarding the depth of water. Such actions are fundamental
to the duties of an OOW, and would have undoubtedly helped to identify the
shallows ahead of the vessel in sufficient time for successful avoiding action to
be taken.

ECDIS provides a potentially invaluable asset to passage planning. However,

there is a danger that many bridge watchkeepers will increasingly trust what
is displayed without question. As this case demonstrates, such trust can
be misplaced. The need for bridge watchkeepers to remain vigilant and
continuously monitor a vessel’s position in relation to navigational hazards
remains valid, regardless of the electronic aids available.

2.5 Watch vector

It is disturbing that, although the safety contour was set at 30m, its associated
alarm did not activate because a watch vector, which defines the predicted
movement of a vessel, had not been set. The setting of a watch vector is
therefore an extremely important feature without which many of the chart
alarms cannot operate. The use, or misuse of a watch vector in this, and other
accidents highlighted in Paragraph 1.12, indicates that the significance of this
function requires emphasising to all ECDIS users.

2.6 Safety management

Positive attitudes to safety and the development of a healthy safety culture need
time to develop, and can only occur when there is a commitment to safety at
the highest level, supported by robust procedures documented in operations or
management manuals. In this case, CFL was a relatively new and expanding
company with a fleet of new and well-equipped ships. The company had been
proactive in arranging for the officers on board CFL Performer to be trained in
the use of the Furuno FEA-2107 before the vessel entered service, and was
in the process of obtaining feedback on the use of ECDIS on board its vessels
when the accident occurred. However, a number of issues related to the safety
management of the vessel, for which Vertom was responsible, indicate that
the implications of the use of ECDIS had not been assessed and that onboard
procedures were not robust. These issues included:
• Following the initial onboard ECDIS training, no further training was
arranged. Consequently, officers who subsequently joined the vessel
were not familiar with the ECDIS and were reliant on their limited previous
experience.
• The complexity of the operation of ECDIS with regard to the number of
user settings required, was not recognised, and no procedures for the
use of the equipment were included in the vessel’s safety management
system. Instructions for the operation of the VDR were also omitted.

23
 • The master did not consider the grounding to be sufficiently serious to
immediately inform the DPA or save the VDR data. While there was no
apparent damage to the vessel or the marine environment, the accident
raised a number of safety issues of which the DPA should undoubtedly
have been made aware.
• Electronic records pertinent to the accident were deleted from the ECDIS.
• No consideration had been given to the duration of the handover required
for crew joining the vessel.

In order to develop, a safety management system must be modified and updated

as lessons are learned from accidents, hazardous incidents and other operational
situations. It is therefore important that, unlike in this instance, clear guidance
for the reporting of such occurrences and the preservation of evidence, including
electronic data from VDRs, ECDIS’ and other systems, is provided to ships’ crews.

24
Section 3 - CONCLUSIONS
3.1 Safety issues
3.1.1 Safety issues directly contributing to the accident which have resulted in
recommendations
1. The route plan took the vessel across Haisborough Sand, and in-built
safeguards in the vessel’s ECDIS which are intended to prevent accidents
of this nature were not utilised and system warnings were not acted upon.
[2.2]
2. The planner’s check of the route plan was only cursory and was not
cross-checked by the master. [2.2]
3. The deck officers had not been trained in the use of ECDIS, and no
procedures on the system’s use were included in the vessel’s SMS. They
were therefore ignorant of many of the system requirements and features
and operated the system in a very basic and inherently dangerous
manner. [2.3.1, 2.6]
4. Over the next 10 years, ECDIS will replace paper charts as the primary
planning and monitoring media on board most vessels. Therefore the
need for the inclusion of specific ECDIS competences within the STCW
Code and for mandatory training in its use is compelling. [2.3.1]
5. A review of the content of the IMO ECDIS course would be beneficial
in order to take into account the experience gained in the use of the
system, the lessons learned from this and other accidents, and to ensure
the course continues to meet the requirements of the maritime industry.
[2.3.2]
6. Differences between ECDIS’ in terms of menus, terminology and
equipment interface can be marked, and proficiency in the use of a
particular system is best served by the provision of equipment specific
training. [2.3.3]

3.1.2 Other safety issues identified during the investigation also leading to
recommendations
1. To enable lessons to be learned from accidents, hazardous incidents and
other operational situations, it is important that clear guidance for the
reporting of such occurrences and the preservation of evidence, including
electronic data from VDRs, ECDIS’ and other systems, is provided to
ships’ crews. [2.6]

25
3.1.3 Safety issues identified during the investigation which have not resulted
in recommendations but have been addressed
1. The OOW placed an undue reliance on the ECDIS, and it is possible that
the grounding could have been avoided had he remained vigilant and
continuously monitored the vessel’s position in relation to navigational
hazards. [2.4]

2. The setting of a watch vector on the ECDIS, without which many of the
chart alarms cannot operate, is an extremely important feature which
merits emphasis. [2.5]

26
Section 4 - action taken
4.1 Vertom Scheepvaart & Handelmaatschappij b.v.
Vertom, the vessel’s safety manager, has:
• Issued a fleet circular highlighting the circumstances and causes of this
accident (Annex B).
• Implemented a policy requiring all navigating officers on board its vessels
to complete generic training in the use of ECDIS and to be familiar with
the ECDIS fitted (Annex C).
• Revised its instructions to masters regarding its requirements for
informing the DPA during or following an onboard emergency.
• Stated an intention to practise its emergency response procedures with
its vessels more frequently.

4.2 CFL Shipmanagement B.V.

CFL Shipmanagement B.V. has:
• Increased its number of employees and obtained its own DOC. It has
assumed responsibility for the safety management of its fifth vessel to
enter service, and intends to take responsibility for the remaining four as
soon as possible.
• Implemented a policy which requires all deck officers joining its vessels
to have completed training in the use of ECDIS, and has taken steps to
ensure they are familiar with the systems fitted on board its vessels.
• Issued a circular to its fleet highlighting the circumstances of this
accident, and of the need to: report accidents and incidents; be trained in
the use of ECDIS; and to navigate using all available means (Annex D).
• Produced its own ISM Manual, which includes requirements for the
reporting of accidents and incidents and the saving of VDR data.
• Audited its crew management company.

4.3 FURUNO (European Branch Office)

Furuno (European Branch Office) has:
Undertaken to adopt in its next generation of ECDIS software, a number of
revisions resulting from this investigation. These include the addition of the
names of passage plans in the voyage log file, and the improvements to the
security of recorded data.

27
Section 5 - recommendations
The Maritime and Coastguard Agency is recommended to:
2008/186 Continue to strongly support the expeditious adoption of current
proposals for the formal inclusion of an ECDIS competence and its
mandatory assessment in the STCW Code and, in doing so, to press for
an urgent review of the IMO model course syllabus for ECDIS training to
ensure it remains fit for purpose, and that successful completion of the
course is determined by examination and practical assessment.

International Chamber of Shipping is recommended to:

2008/187 Through its member organisations, remind ship owners:
• Of their obligation to ensure that all bridge watchkeeping officers
are familiar with the navigational systems in use and to encourage
the use of both generic and specific system training courses to
help meet this obligation.
• Of the need for ships’ crews to preserve all recorded information,
including VDR, ECDIS and other electronic data, following an
accident or incident.

The International Association of Maritime Institutions, the Association of

Maritime Educational and Training Institutions Asia-Pacific Regions, and the
Comité International Radio- Maritime are recommended to:
2008/188 Encourage their members who provide training in ECDIS to align it as
closely as possible with the IMO model course, and to determine the
successful completion of such training through practical assessment and
examination.

Vertom Scheepvaart & Handelmaatschappij B.V. and CFL Shipmanagement B.V.

are recommended to:
2008/189 Ensure that procedures on the use of ECDIS are included in their
vessels’ safety management systems.

Marine Accident Investigation Branch

December 2008

Safety recommendations shall in no case create a presumption of blame or liability

28