Why Didn’t We Talk About Bridge Resource Management? More lessons from the loss of HMNZS Manawanui
- Mike Mason
- Apr 13
- 6 min read
This blog is sort of a sequel to the blog published a fortnight ago. If you haven't read the last blog, you can do so here. If you haven't, don't worry, you can read this one first which is aimed at explicitly discussing BRM.
The Story
On the evening of 5 October 2024, HMNZS Manawanui was conducting survey operations off the southern coast of Upolu, Samoa. The ship was operating in challenging conditions, in close proximity to a reef, while attempting to maintain a precise survey pattern.
As the situation developed, control inputs did not produce the expected response. The vessel remained in autopilot, continued on a heading toward land, and eventually grounded at speed. The ship was lost. Everyone survived.
The official report explains what happened in detail. What it does not explain is something far more useful: Why a failure of situational awareness — one of the most well-understood risks in complex operations — was not meaningfully addressed through the lens of Bridge Resource Management.
The missing conversation
The report makes clear that situational awareness degraded over time. The ship left the survey area. Control inputs were misunderstood. The autopilot remained engaged when it should have been disengaged.
These are not technical failures. They are coordination failures. Moreover, they are awareness failures. They are exactly the kinds of breakdowns that Bridge Resource Management is designed to prevent.
Across aviation, where the equivalent concept is Crew Resource Management, studies have consistently shown that a significant proportion of accidents involve failures in communication, leadership, and situational awareness. Estimates suggest that nearly a third of aircrew-related accidents involve at least one CRM-related failure. https://aviation.stackexchange.com/questions/50835/is-there-statistical-evidence-of-the-benefits-of-crm
So now we have to ask a simple question: If situational awareness was central to this event, why is BRM largely absent from the discussion?
When a concept becomes invisible
One possibility is that BRM has become so embedded in maritime operations that it is no longer explicitly discussed. It is assumed to be present, assumed to be understood, and therefore not treated as something that requires attention or reinforcement.
This is a familiar pattern in high-performance organisations. Concepts that are widely taught can become invisible over time, particularly when they are difficult to measure and do not appear directly in procedures or checklists. When investigations focus on what can be observed and documented, such as actions taken or procedures followed, the underlying coordination and communication behaviours can fade into the background.
The result is a report that describes what people did, without fully exploring how they were working together and why they did what they did.
The comfort of technical explanations
The report explicitly avoids “root cause analysis” in favour of identifying multiple interacting factors, which is a sensible approach in complex systems. As an aside, the root cause of all accidents is Adam and Eve. You're welcome.
Even so, much of the analysis remains anchored in observable actions and procedural alignment. The autopilot was not disengaged. The correct initial actions were not taken. The ship was put on a heading towards land. These statements are accurate. They are also incomplete and don't help us very much.
They are easier to document than the more difficult question of how the bridge team was thinking, communicating, and making sense of the situation as it evolved.
Non-technical skills are inherently harder to capture. They require interpretation, context, and often uncomfortable conversations about culture, leadership, and team dynamics. It is far simpler to describe what happened than to explain how people collectively made sense of what was happening.
We’ve seen this before
Aviation faced this problem decades ago. In the 1970s, a series of major accidents revealed that highly trained crews were still making catastrophic errors. This wasn't because they lacked technical ability, but because of (for example) breakdowns in communication, authority gradients, and shared situational awareness.
Crew Resource Management did not emerge because people suddenly became interested in teamwork. It emerged because highly trained, highly disciplined crews were still crashing perfectly serviceable aircraft.
Since then, CRM has been adopted globally. Not as a theoretical concept, but as a practical response to real-world failure. Studies have shown consistent improvements in communication, teamwork, and decision-making following CRM training, alongside measurable improvements in safety attitudes.
Some military aviation studies have even demonstrated reductions in accident and incident rates following CRM implementation. We may not be able to draw a perfectly straight line from CRM training to accident reduction in a dataset. Accidents are rare, complex, and influenced by many interacting factors.
What we can say is this: CRM has been sustained for decades because it improves how teams operate under pressure. And it has been adopted across multiple industries—including maritime—because it works.
A system question, not a people question
The Manawanui report identifies a range of contributing factors including training, supervision, leadership, and operational pressure. These are all relevant.
What remains less clear is how those factors influenced the team’s ability to function as a cohesive unit on the bridge at the time of the incident.
Was there a shared understanding of the situation?
Were concerns voiced and acknowledged?
Did everyone have the same mental model of what the ship was doing?
Was there a clear transition from monitoring to intervention when things started to drift?
Without exploring these questions, the picture remains incomplete. Situational awareness is not just something individuals have in isolation. It is something teams create together.
The risk of what we don’t say
When a report does not explicitly engage with non-technical skills, there is a risk that organisations default to more familiar responses.
Procedures are updated.
Checklists are refined.
Additional risk controls are introduced.
These actions can create the appearance of improvement. They do not necessarily address the underlying issue. When a report identifies degraded situational awareness yet avoids the very discipline designed to manage it, it leaves a gap that procedures alone will not fill.
If the challenge was a breakdown in shared situational awareness, then adding more procedural complexity may make the problem harder rather than easier to manage. What is needed instead is a deliberate focus on how teams operate in real conditions, how they communicate under pressure, and how they maintain a shared understanding of evolving situations.
This is the domain of Bridge Resource Management.
What could have been said
The report itself asks whether other systems or processes within the maritime community could have improved situational awareness or helped prevent the loss of the ship. This is precisely where BRM should have been brought into the conversation.
Not as a generic recommendation, but as a practical framework for understanding what happened on the bridge and how similar situations might be handled differently in the future.
There is an opportunity here to move beyond simply describing actions and towards understanding interactions.
While it takes effort, we need to explore how the team functioned, not just what the team did. We need to identify how awareness was built, shared, and, ultimately, degraded.
Final thought
The loss of HMNZS Manawanui was more than a failure to follow procedures or execute technical actions correctly.
It was a failure of shared understanding in a dynamic and time-critical situation. That is precisely the kind of problem that Bridge Resource Management is designed to address.
The absence of BRM in this report is not neutral. It shapes how organisations respond. If the response focuses on procedures instead of how people actually work together, then the next version of this story is already being written.
In complex environments, safety is not just about what people do. A lot of it is about how they work together to understand what is happening.
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Mike Mason and Sam Gladman are the co-founders of On Target, a leadership and team development company that brings elite fighter pilot expertise into the corporate world. With decades of combined experience in high-performance aviation, they specialise in translating critical skills such as communication, decision-making, and teamwork into practical tools for business. Through immersive training and cutting-edge simulation, Mike and Sam help teams build trust, improve performance, and thrive under pressure—just like the best flight crews in the world.
If you'd like to learn more about how On Target can help your team, contact Mike and Sam at info@ontargetteaming.com.
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