Loss of bridge control: Human failure is normal – context is key

Human error is often blamed in bridge control accidents, but numerous factors can contribute. Procedures, system design, fatigue, workload, communication, and established practices can all increase the likelihood of failure. Recognising context is essential to prevent future incidents. As investigators noted, human failure is normal and often predictable. Shipping companies must identify where and why it can occur, and take steps to support humans to reduce the likelihood of mistakes.

Risk assessments for safety-critical tasks should identify not just what can go wrong, but also the conditions that make mistakes more or less likely. These are known as performance influencing factors (PIFs). In some accidents, routine became risky when experienced crew members felt confident following documented procedures but found them lacking in actual practice. Complacency can set in when systems function flawlessly most of the time, leading even experienced operators to treat safety critical situations as routine.

Companies should review bridge team briefings prior to entering confined or congested waters, as they offer a chance to remind crews of the safety-critical nature of bridge control settings. Local practices can also replace procedures, creating latent risks that surface only under specific conditions. Regular emergency steering gear room drills, mandated every three months, can help verify correct procedures.

Effective signage and ergonomic design are crucial. In one case, confusing signage and unclear panel illumination contributed to the misunderstanding of emergency operation authority. Procedures should be practical and easy to understand, not buried in lengthy documents. Pressure and fatigue can severely impact performance, as seen in several accidents where crews faced intense cognitive workload and time pressure, leading to rapid performance degradation.

Fatigue was a factor in at least two cases, and its impact on crew response was not actively addressed.

Communication is vital; distraction can divert attention from critical tasks. In some accidents, the watch officer did not receive timely reminders about critical drills, and in the bridge wing joystick case, there was no closed-loop communication for a safety-critical step. Human-machine interfaces, while helpful, can also create confusion when systems integrate excessively.

Investigations into fishing vessel accidents highlighted the need for clearer mode indication, stronger safeguards, and system designs that minimise confusion risks.

Companies should foster a culture of open communication and encourage speaking up, especially regarding safety-critical control systems. Learning and practicing procedures can also mitigate risks. Recurring investigators emphasized the importance of crew feedback on control system usability and ergonomic adjustments to enhance human-machine interface effectiveness. By considering these factors, shipping companies can better prevent bridge control accidents and ensure safer operations.