Lessons Learned -- Morehead City LT Hagee 02 May 00 Safe Navigation Lessons Learned -- Morehead City LT Hagee 02 May 00
Overview Morehead City Detailed Description Findings Recommendations Summary Discussion
Detailed Description See Chart
Findings - General Watchstanders were experienced Four unqualified personnel in watch positions Ship was overconfident in pilot’s ability Ship entered port at excessive speed Did not adhere to watchbill CO/OOD/Conn/Pilot failed to keep Navigation picture Risks associated w/ low vis not considered Deck Log kept improperly
Findings - Bridge Navigation “No Fix” and non-concurrence not reported Flood tide briefed inadequately Plot shifted to CIC when CIC not prepared Set and drift not provided Didn’t warn CO/OOD/Conn of shoal water Navigator did not insist CO/OOD/Conn acknowledge Did not question 20 kts (Pilot’s recommendation)
Findings - Piloting & CIC Did not inform Nav CIC had no fix prior to shift Did not inform bridge CIC was not manned and ready (CICWO not present) Piloting Officer not at Nav Brief Bearings and ranges to buoys not marked as Eps
Findings - Bridge and CIC Navigation DRs not plotted in CIC and Bridge Plotting sloppy Bearing books not properly used and did not correlate to plotted fixes Fix times not correlated between CIC and bridge Shifted charts simultaneously
Findings - OOD and Conn OOD Conn Overconfident in pilot’s ability Not involved in the Navigation picture Failed to set low visibility at <1nm IAW Standing Orders Conn Conflict between pilot and OOD’s orders
Recommendations Institute ORM during all evolutions Re-emphasize critical nature of special evolutions Navigation Check Ride Increased scrutiny of watchbills Harbor pilots used in an ADVISORY role
Summary Overconfidence in pilot Inattention to low visibility considerations Improper navigation procedures
Discussion