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Safety Recommendation Details

Safety Recommendation M-16-001
Details
Synopsis: On March 9, 2015, at 1230 central daylight time, the inbound bulk carrier Conti Peridot collided with the outbound tanker Carla Maersk in the Houston Ship Channel near Morgan’s Point, Texas. The collision occurred in restricted visibility after the pilot on the Conti Peridot was unable to control the heading fluctuations that the bulk carrier was experiencing during the transit. As a result, the Conti Peridot crossed the channel into the path of the Carla Maersk. No one on board either ship was injured in the collision, but an estimated 2,100 barrels (88,200 gallons) of methyl tert-butyl ether spilled from the Carla Maersk, and the two vessels sustained about $8.2 million in total damage. The National Transportation Safety Board determines that the probable cause of the collision between bulk carrier Conti Peridot and tanker Carla Maersk in the Houston Ship Channel was the inability of the pilot on the Conti Peridot to respond appropriately to hydrodynamic forces after meeting another vessel during restricted visibility, and his lack of communication with other vessels about this handling difficulty. Contributing to the circumstances that resulted in the collision was the inadequate bridge resource management between the master and the pilot on the Conti Peridot.
Recommendation: TO BREMER BEREEDERUNGSGESELLSCHAFT MBH & CO (BBG): Inform your personnel about the circumstances of this accident, and require training and audit procedures to ensure that bridge resource management is practiced during all operations.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Reconsidered
Mode: Marine
Location: Morgan's Point, TX, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA15MM017
Accident Reports: ​Preliminary Marine Accident Summary - Houston Ship Channel, Buoy 89-90, Upper Galveston Bay, TXCollision between Bulk Carrier Conti Peridot and Tanker Carla Maersk Houston Ship Channel near Morgan’s Point, Texas
Report #: MAR-16-01
Accident Date: 3/9/2015
Issue Date: 6/22/2016
Date Closed: 11/27/2018
Addressee(s) and Addressee Status: BBG Ship Management (Closed - Reconsidered)
Keyword(s):

Safety Recommendation History
From: NTSB
To: BBG Ship Management
Date: 11/27/2018
Response: We note that, in March 2015, you distributed an internal document to BBG personnel that discussed the circumstances of this collision. We also note that you developed a presentation highlighting the importance of good communication and cooperation on the bridge by all personnel, including the pilot, and that, since 2015, this presentation has been used in crew training sessions and senior officer briefings. Also since 2015, your nautical officers have undergone recurring, scenario based, bridge simulator training, which and includes a situation similar to the Conti Peridot/Carla Maersk collision. We note that you conduct annual internal audits on board all vessels to address bridge team procedures and management with all personnel involved in vessel navigation. Further, you have revised some of your bridge-team–related procedures and checklists with additional details and information, and we understand that these procedures were incorporated into BBG’s safety management system in June 2015 and implemented on August 31, 2015. We believe that your efforts to educate BBG personnel about the circumstances of this collision, to incorporate initial and recurring simulator training that focuses on bridge resource management and is scenario-based, and to implement audits that address bridge-team–relevant procedures and bridge team management satisfy the intent of this recommendation. However, because these actions were implemented in 2015, which is before this recommendation was issued, Safety Recommendation M-16-1 is classified CLOSED-RECONSIDERED.

From: BBG Ship Management
To: NTSB
Date: 5/9/2018
Response: -From Captain Henning Pulmer, Designated Management Representative hbv, Fleet Safety/ Security Officer, Senior DPA/CSO: First of all apologies for my late reply to your letter from December 2017. It literally just arrived a week ago on my desk! As for the measures taken and procedures implemented: •?Already shortly after the incident (in March, 2015) a circular information has been issued to the company’s fleet, detailing what happened and under which circumstances. •?A (company-) internal investigation report was written by me in May 2015, which was distributed throughout our fleet, and a presentation was produced for showing during our regular crew training sessions which are held several times per year in the country of origin of our seafarers, as well as during senior officer briefings prior to their employment on one of our vessels, where the importance of good communication and cooperation within the complete bridge team (which includes the pilot) is highlighted. •?Training Centres (Bridge Simulators) were selected and contracted by end of 2015 where our nautical officers have to attend a simulator training on a regular basis. The selection was based on the training centre’s ability to carry out trainings company specified situations, one of which contains a situation similar to the Conti Peridot/ Carla Maersk collision. •?It has been implemented to discuss the Bridge Team relevant procedures and the Bridge Team Management with all personnel involved in navigation of the vessel in course of the Internal Audits (which are carried out on board each vessel at least annually). Furthermore: •?Documented Procedure for “Pilotage” was amended with more details about o Responsibilities o Preparatory steps/ planning of piloted passages o Execution of piloted passages •?Respectively, forms and checklists to assist the forming bridge team (incl. Pilot) with respective information were amended, as: o Checklist Pilotage o Master/ Pilot Exchange o Pilot/ Master Exchange o Pilot Card •?Documented Procedure for “Navigation in Restricted Visibility” was specified •?Respectively a checklist for Navigation in Restricted Visibility was introduced The above Procedures and System forms have been introduced into the company’s Safety Management System in June 2015 and finally implemented on August 31, 2015 We therefor deem to have fulfilled Safety recommendation M-16-1 already prior to having been issued. Further communication is appreciated to be received by email instead of hardcopy, and I would be delighted to receive your comments.

From: NTSB
To: BBG Ship Management
Date: 12/11/2017
Response: We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others. We normally expect actions to address our recommendations to be completed within 3 to 5 years, and we have yet to hear from you regarding your progress toward addressing this recommendation. We would appreciate receiving a response within 90 days indicating any actions you have taken or plan to take to implement this recommendation; until then, it will retain its current classification of “Open—Await Response.” For additional background information about this safety recommendation, please refer to section 2.1, “Inadequate Bridge Resource Management” (pages 22–23) in our report Collision Between Bulk Carrier Conti Peridot and Tanker Carla Maersk Houston Ship Channel Near Morgan’s Point, Texas, March 9, 2015, which can be found at: https://www.ntsb.gov/investigations/AccidentReports/Reports/MAR1601.pdf. Please update us regarding your actions to address Safety Recommendation M -16-1.