As mentioned in my editorial, shore authorities nvestigating maritime incidents are seemingly blurring the delineation between civil & criminal law in seeking to condemn seafarers. Although this case hasn’t led to any criminal proceedings the following article, which has been collated from several press reports of this incident, suggests that pilots need to be very alert to this worrying trend.

In December 2008 a pilot was on board the APL Sydney when the decision was made to abort the berthing and the vessel was instructed to anchor in the Port Phillip Bay anchorage within the Melbourne compulsory pilotage district. With the weather deteriorating, the pilot left the ship before the vessel was fully brought up to the anchor and proceeded ashore. Shortly after anchoring, the APL Sydney started dragging the anchor towards a gas pipeline and, realising the danger, the Captain requested permission from the harbour authority to weigh anchor and move to a safer location in the anchorage.

The harbour authority refused to permit the ship to move without a pilot on board and instructed the Captain to wait for the pilot to return to the ship. By this time the pilot cutter was 45 minutes away from the vessel but turned round and returned to the anchorage with the pilot.

The vessel continued to drag anchor towards the gas pipeline but the harbour authority took no action. Shortly before the pilot re-boarded, the anchor fouled the pipeline and parts of the windlass shattered rendering it unusable. Once he boarded the vessel, the pilot ordered an ahead movement and suggested that the cable be cut. The ahead movement ruptured the pipeline which cut of the ethane supply from Esso’s Bass Strait gas field for four months.

Naturally, the lawyers are having a field day and at the time of writing the claims are approaching $70M and rising. With such a large claim it is inevitable that the actions of all involved are subjected to scrutiny. Referring to the ports actions, the judge criticised the port authority for not having an emergency plan to deal with a gas leak and, despite having been alerted to the risk by the Captain, stated that,  ”…the evidence does not reveal that harbour control took any active step for about 25 minutes to deal with the situation, far less to assist or facilitate the master taking steps to prevent the ship getting too close to the pipeline”.

With respect to the Captain, the judge has sympathised with his predicament at having been placed in a seemingly impossible position without support but hasn’t exonerated him stating that he should have ”ignored the refusal of harbour control at 15:07 to allow him to move the ship  and begun lifting anchor  then and there. It was the time to act. His instinctual reaction to the situation was correct. His primary responsibility was to ensure the safety of his ship, her crew and cargo and to prevent the anchor damaging the pipeline. I do not accept that he was absolved of his right and duty to exercise that responsibility by the unhelpful refusal of harbour control to give its permission”.

With respect to the pilot, the judge considered that his decision to leave the vessel before it was safely at anchor amounted to a breach of his obligations.

‘‘If anything went wrong with the anchoring, as it did in this case, the master [Xu] would be in the invidious position of potentially breaching the compulsory pilotage requirements of the Port of Melbourne were he to use the engines to manoeuvre the ship or attempt to re-anchor her,.

The judge found that when the pilot returned to the vessel his advice to put the engine ahead ”had no justification in the circumstances’‘ and he ”did not provide the master with the level of advice that a seafarer was entitled to expect from a person with an unlimited pilot’s licence for Port Phillip Bay”. The judge said both the pilot and Captain were ”negligent”.

These judgements are not final and will be subject to appeal and the case is still a civil rather than a criminal one. However, the case again highlights a worrying blurring of the difference between civil and criminal cases when it comes to shipping incidents.

In my opinion the harbour authority have been let off lightly by the judge because since this disaster happened in an area under their jurisdiction, the port control should have noticed that the ship was dragging, immediately recognised the potential risk and instructed the Captain to weigh anchor and move clear of the pipeline. Their decisions on that day are seemingly irresponsible as well as illogical! Despite this, the judge seemingly hasn’t found the port “negligent” along with the pilot and Captain! Whatever the reasoning behind the judgement, the fact that the pilot has been criminalised cannot now be ignored.  The actions of the pilot that day are recognisable as common practice in many ports and therefore serve as a warning that we must carefully review our procedures.

JCB

PS: since writing the original article the Australian Transport Safety Bureau (ATSB) have published their full report into the incident which can be accessed by clicking here

MV Pacific Dawn Photo: Unknown from web

All in a day’s work

With shipping and seafarers generally being associated with negative press reports it is extremely rare for a positive shipping report to appear in any of the mainstream press. It is therefore with pleasure that I came across the following press report from Brisbane.Pilots face similar “challenges” on a daily basis so it’s good to see at least one pilot being praised for his skills in averting a disaster. However what is most alarming is the cause. A fuse affected by a salt water leak?? JCB

PASSENGERS on a cruise ship that stopped just 70m from the Gateway Bridge in Brisbane have paid tribute to the pilot and captain who saved them from disaster. Brisbane Pilot Captain Peter Liley was the pilot on board the 245m Pacific Dawn when the liner lost all power and steering just 700m away from the six-lane bridge over the Brisbane River. Two tugs got the vessel under control, bringing her to a complete standstill 70m short of the bridge. A passenger observed that “The situation was handled very well by Captain Turnbull and his crew, and passengers were informed of all developments.” Captain Liley said he managed to stop the ship before it got to the Gateway. “I was piloting the ship and we lost all propulsion. It’s unusual, but we are trained for these sorts of things. If it was under the Gateway we could have drifted clear but it was before the Gateway.”

Capt Liley said a ship without power was prone to drift, and there was a danger it could not be stopped before hitting the bridge’s pylons. “We used two tugs to pull the ship up, and we pulled up before the Gateway. We then waited on the chief engineer on what services he could provide, but he couldn’t provide any services so we devised a plan to take the `dead’ ship back to Hamilton.” He added that the ship’s captain had investigated what caused the fault and believed a fuse had been affected by a saltwater leak. A spokesman for Carnival Australia, which operates the Pacific Dawn, said the cruise liner had suffered power problems but the fault was not a major one. “It was a temporary loss of power,” the spokesman said. “It was a controlled situation. “The ship is OK and will set off for a South Pacific cruise.

In contrast, The National Transportation Safety Board (NTSB) report, which has now been published, provides a very detailed account (161 pages!) of the events leading up to the incident and reveals that John Cota’s error was compounded by failures of the bridge team and the failure of the VTS to provide support at a critical time.  Although the report catalogues “Human element” failures, in my opinion it doesn’t identify any actions which could be identified as criminally negligent. It is therefore all the more worrying that in sentencing John Cota to prison, the prosecutors have set a precedent that will encourage other legal teams around the world to criminalise the pilot.

The following analysis is extracted from the NTSB report and press reports from the trial but the opinions expressed in it are my personal views.

The Cosco Busan after the allision with the Bay Bridge.   Photo: NTSB

SUMMARY

On Wednesday, November 7, 2007, about 0830 Pacific standard time, the Hong Kong registered, 901-foot-long containership M/V Cosco Busan allided with the fendering system at the base of the Delta tower of the San Francisco–Oakland Bay Bridge. The ship was outbound from berth 56 in the Port of Oakland, California, and was destined for Busan, South Korea. Contact with the bridge tower created a 212-foot-long by 10-foot-high by 8-foot-deep gash in the forward port side of the ship and breached the Nos. 3 and 4 port fuel tanks and the No. 2 port ballast tank. As a result of the breached fuel tanks, about 53,500 gallons of fuel oil were released into San Francisco Bay. No injuries or fatalities resulted from the accident, but the fuel spill contaminated about 26 miles of shoreline, killed more than 2,500 birds of about 50 species, temporarily closed a fishery on the bay, and delayed the start of the crab-fishing season. Total monetary damages were estimated to be $2.1 million for the ship, $1.5 million for the bridge, and more than $70 million for environmental cleanup. The National Transportation Safety Board determines that the probable cause of the allision of the Cosco Busan with the San Francisco–Oakland Bay Bridge was the failure to safely navigate the vessel in restricted visibility as a result of (1) the pilot’s degraded cognitive performance from his use of impairing prescription medications, (2) the absence of a comprehensive pre-departure master/pilot exchange and a lack of effective communication between the pilot and the master during the accident voyage, and (3) the master’s ineffective oversight of the pilot’s performance and the vessel’s progress. Contributing to the accident was the failure of Fleet Management Ltd. to adequately train the Cosco Busan crewmembers before their initial voyage on the vessel, which included a failure to ensure that the crew understood and complied with the company’s safety management system. Also contributing to the accident was the U.S. Coast Guard’s failure to provide adequate medical oversight of the pilot in view of the medical and medication information that the pilot had reported to the Coast Guard.

NTSB CONCLUSIONS

1. The following were neither causal nor contributory to the accident: wind and current; the vessel propulsion and steering systems; the bridge navigation systems; bridge team response to orders; vessel harbor traffic; navigation aids, including the RACON at the center of the Delta–Echo span; maintenance of a proper lookout; pilot training and experience; and vessel traffic service equipment and operational capability.

2. The California Department of Transportation’s assessment of damage to the San Francisco– Oakland Bay Bridge following the allision was timely and appropriate.

3. The California Department of Transportation’s decision to allow the bridge to remain open to traffic after the allision was appropriate.

4. In this accident, the bridge tower fendering system worked as intended to protect the pier structure and to limit damage to the striking vessel to the area above the waterline.

5. The pilot’s order for hard port rudder at the time of the allision was appropriate and possibly limited the damage to the vessel and the bridge fendering system.

6. Although the pilot had been diagnosed with sleep apnea, he was being treated for the condition, and there was no evidence that he was sleep-deprived at the time of the accident.

7. As evidenced by his prescription history and duty schedule, the pilot was most likely taking a number of medications, the types and dosages of which would be expected to degrade cognitive performance, and these effects were present while the pilot was performing piloting duties, including on the day of the accident.

8. The Cosco Busan pilot, at the time of the allision, experienced reduced cognitive function that affected his ability to interpret data and that degraded his ability to safely pilot the ship under the prevailing conditions, as evidenced by a number of navigational errors that he committed.

9. The pilot and the master of the Cosco Busan failed to engage in a comprehensive master/pilot information exchange before the ship departed the dock and failed to establish and maintain effective communication during the accident voyage, with the result that they were unable to effectively carry out their respective navigation and command responsibilities.

10. The master of the Cosco Busan did not implement several procedures found in the company safety management system related to safe vessel operations, which placed the vessel, the crew, and the environment at risk.

11. The interactions between the pilot and the master on the day of the allision were likely influenced by a disparity in experience between the pilot and the master in navigating the San Francisco Bay and by cultural differences that made the master reluctant to assert authority over the pilot.

12. Because the Cosco Busan master was the only crewmember to have been drug tested in a timely manner, no conclusive evidence exists as to whether the use of illegal drugs by the other crewmembers played a role in the accident.

13. Vessel Traffic Service San Francisco personnel, in the minutes before the allision, provided the pilot with incorrect navigational information that may have confused him about the vessel’s heading.

14. Vessel traffic service communications that identify the vessel, not only the pilot, would enhance the ability of vessel masters and crew to monitor and comprehend vessel traffic service communications.

15. Although Vessel Traffic Service San Francisco personnel should have provided the pilot and the master with unambiguous information about the vessel’s proximity to the Delta tower, the Safety Board could not determine whether such information, had it been provided, would have prevented the allision.

16. The lack of U.S. Coast Guard guidance on the use of vessel traffic service authority limited the ability of Vessel Traffic Service San Francisco personnel to exercise their authority to control or direct vessel movement to minimize risk.

17. Even though the pilot’s personal physician, who prescribed the majority of medications to the pilot, was aware of the pilot’s occupation and his medical history, including his documented history of alcohol dependence, he continued to inappropriately prescribe medications that, either individually or in concert, had a high likelihood of adversely affecting the pilot’s job performance.

18. Although the pilot did not disclose to the physician who conducted his January 2007 medical evaluation all of his medical conditions or medication use, as he was required to do, the physician exercised poor medical oversight on behalf of the California Board of Pilot Commissioners by finding the pilot fit for duty despite having collected sufficient information regarding his multiple medical conditions and medications to call into question his ability to perform his piloting duties safely.

19. Although the pilot did not disclose to the U.S. Coast Guard and the California Board of Pilot Commissioners all of his medical conditions or medication use, as he was required to do, the information he did provide should have been sufficient to prompt the Coast Guard, at a minimum, to conduct additional review of the pilot’s fitness for duty.

20. The U.S. Coast Guard, which had the ultimate responsibility for determining the pilot’s medical qualification for retaining his merchant mariner’s license, should not have allowed the pilot to continue his duties because the pilot was not medically fit.

21. The U.S. Coast Guard’s system of medical oversight of mariners continues to be deficient in that it lacks a requirement for mariners to report changes in their medical status between medical evaluations.

22. Fleet Management Ltd. had failed to adequately train the Cosco Busan crewmembers, who were new to the vessel, who had not worked together previously, and who for the most part were new to the company, and this failure contributed to deficient bridge team performance on the day of the accident.

23. Providing a safety management system manual to the Cosco Busan crew only in English and not also in the vessel’s working language limited the crewmembers’ ability to review and follow the SMS.

24. Fleet Management had not successfully instilled in the Cosco Busan master and crew the importance of following all company safety management system procedures.

25. The failure of the U.S. Coast Guard and the California Department of Fish and Game’s Office of Spill Prevention and Response to quickly quantify and relay an accurate estimate of the quantity of oil spilled to the Unified Command did not affect the overall on-water recovery effort in this accident.

26. The Federal on-scene coordinator failed to aggressively use the resources available to him to obtain timely and accurate information about the extent of the spill in order to fulfill his responsibilities.

27. Effective communication regarding response activities was established and maintained between the oil spill response organizations, the qualified individual, the U.S. Coast Guard, and the Unified Command on the day of the accident.

28. The designated oil spill response organizations’ level of response to the Cosco Busan fuel oil spill was timely and effective.

29. A mechanism for the collection and regular communication among pilot oversight organizations of pilot-related performance data and information regarding pilot oversight and best practices would enhance the ability of those organizations to effectively oversee pilots.

30. Recently implemented international regulations with regard to the protection of fuel oil tanks on nontank vessels will, over time, reduce the likelihood of oil spills in mishaps such as occurred with the Cosco Busan.

Probable Cause

The National Transportation Safety Board determines that the probable cause of the allision of the Cosco Busan with the San Francisco–Oakland Bay Bridge was the failure to safely navigate the vessel in restricted visibility as a result of (1) the pilot’s degraded cognitive performance from his use of impairing prescription medications, (2) the absence of a comprehensive pre-departure master/pilot exchange and a lack of effective communication  between the pilot and the master during the accident voyage, and (3) the master’s ineffective oversight of the pilot’s performance and the vessel’s progress. Contributing to the accident was the failure of Fleet Management Ltd. to adequately train the Cosco Busan crewmembers before the accident voyage, which included a failure to ensure that the crew understood and complied with the company’s safety management system. Also contributing to the accident was the U.S. Coast Guard’s failure to provide adequate medical oversight of the pilot in view of the medical and medication information that the pilot had reported to the Coast Guard.

NTSB Recommendations

• To the U.S. Coast Guard:
• Propose to the International Maritime Organization that it include a segment on cultural and language differences and their possible influence on mariner performance in its bridge resource management curricula.
• Revise your vessel traffic service policies to ensure that vessel traffic service communications identify the vessel, not only the pilot, when vessels operate in pilotage waters.
• Provide Coast Guard-wide guidance to vessel traffic service personnel that clearly defines expectations for the use of existing authority to direct or control vessel movement when such action is justified in the interest of safety.
• Require mariners to report to the Coast Guard, in a timely manner, any substantive changes in their medical status or medication use that occur between required medical evaluations.
• Establish a mechanism through which representatives of pilot oversight organisations collect and regularly communicate pilot performance data and information regarding pilot oversight and best practices.

To Fleet Management Ltd.:

• When assigning a new crew to a vessel, ensure that all crewmembers are thoroughly familiar with vessel operations and company safety procedures before the vessel departs the port.
• Provide safety management system manuals that are in the working language of a vessel’s crew.

To the American Pilots’ Association:

• Inform your members of the circumstances of this accident, remind them that a pilot card is only a supplement to a verbal master/pilot exchange, and encourage your pilots to include vessel masters and/or the officer in charge of the navigational watch in all discussions and decisions regarding vessel navigation in pilotage waters.

In view of all the factors analysed in the report it is  a seriously alarming development that the pilot has been held solely responsible and condemned as a criminal. As a pilot with 27 years experience some factor evidently caused him to lose situational awareness at a critical point. The medication that he was taking seems to have been a factor in the loss of situational awareness but did this represent a criminal act?  I am no legal expert but I don’t believe that this case should ever have come anywhere near a criminal court. Compare John Cota’s actions with that of a driver of an HGV in Alaska in 2002 whose vehicle collided with a car and killed the two occupants because the driver was watching a film on a DVD player mounted in his cab. That driver faced manslaughter charges but he was acquitted because no law existed prohibiting a driver from operating a DVD in the view of a driver and there are many other cases of road drivers causing death and destruction and walking away unpunished.

In frightening contrast (and I mean to be alarmist here!), the prosecutors in John Cota’s trial were determined to condemn the pilot and this now has set a precedent for any pilot who may be unfortunate enough to have the conduct of a vessel which is involved in an incident that results in pollution or death.  An exaggeration?  Take careful note of these accounts from the trial:

In papers filed in court, prosecutors told the judge that Captain Cota should receive a sentence of incarceration because he was “guilty of far more than a mere slip-up or an otherwise innocuous mistake that yielded unforeseeably grave damage. Rather, he made a series of intentional and negligent acts and omissions, both before and leading up to the incident that produced a disaster that, as widespread as it was, could have had even worse consequences.”

“Captain Cota abandoned ship by not following required safety procedures which then resulted in an environmental disaster”

“The court’s sentence of John Cota should serve as a deterrent to shipping companies and mariners who think violating the environmental laws that protect our nation’s waterways will go undetected or unpunished,” said Joseph P. Russoniello, U.S. Attorney for the Northern District of California. “They will be vigorously prosecuted.”

Imposing a prison sentence rather than a fine, U.S. District Judge Susan Illston said, “I know there is a lot of blame to go around and there were a lot of authors in this tragedy, but I think Captain Cota was right in the middle of that.”

She stated that Congress had made it a crime to engage in negligence resulting in an oil spill “in order to protect the environment against the very kinds of things that have happened here.”

John Cota’s legal team are of the opinion that, by criminalising the pilot, the lessons of the Cosco Busan accident will not be learnt and have identified the following failures that contributed to the disaster:

• The Cosco Busan’s master, Captain Sun, failed to adequately supervise his crew and exercise any responsibility for ensuring the safe navigation of the vessel even though under well-established international law, the master is always in charge of his ship and the pilot acts only as his advisor;

• The Cosco Busan’s master ultimately gave the final approval to sail;
• The crew failed to take fixes at frequent intervals as required by international law, and at least every 5 minutes as required by Fleet Management’s policies, to ensure the safe navigation of the vessel in a congested area such as the San Francisco Bay;
• No one told Captain Cota that the electronic chart on the Cosco Busan was not IMO certified, and therefore should not be used in place of the paper chart;
• The fog signals on the Delta and Echo Towers were not working and cannot be heard at any time on the ship’s bridge recorder;
• The master did not know how to operate his ship’s electronic chart system and failed to either admit his ignorance or ask for help.  As a result, when Captain Cota twice asked him for assistance, the master “guessed” at the meaning of the red symbols, first telling Captain Cota they were “lights on . . . bridge” and later, after VTS called, confirmed they marked the “center of the bridge”;
• The crew falsified various checklists and work logs (i.e., the work logs reflected that the crew was getting more rest than was actually the case);
• At the master’s direction, the crew collaborated on their “story,” and continued to be less than forthcoming even though the government gave them immunity from prosecution.  The master in particular made statements under oath at various times that he later repudiated during his Rule 15 deposition.
• The master never told Captain Cota that he did not know or understand the symbols on his electronic chart or that he could have “queried” the symbols and learned that they were the red/green/red buoys in front of the Delta Tower;
• At the direction of Fleet Management’s Superintendents, the crew falsified documents after the accident to make it appear that the ship’s records were “complete” for the upcoming audit and/or government investigation;
• The Chief Officer abandoned his post at the bow of the ship and went to the mess hall to have a “meal and a smoke” shortly before the accident and later lied about this fact to the Coast Guard;
• The crew aboard the vessel, including the master, failed to adequately perform its duties in violation of international law—in particular, there was no pre-departure passage planning and none of the mandatory bridge team management procedures were followed
• The master failed to direct his crew to prepare a berth-to-berth passage plan prior to departing the Port of Oakland even though Fleet Management’s own policies required such a plan;
• The master failed to place a dedicated lookout on the bridge on the morning of November 7, 2007;
• The radars aboard the Cosco Busan were not properly tuned: the gain had been turned up considerably to compensate for the anti-clutter device that was mistakenly left in auto-mode by the master while his ship was in the Bay;
• The master also violated international law when he claimed not to know that the Cosco Busan’s intended route to sea was through the Delta-Echo span of the Bay Bridge or that the course drawn by his crew on his ship’s paper chart was not through the center of the span but was much closer to the Delta bridge tower
• Fleet Management’s Superintendents, who were on board the ship on November 7, 2007 before the ship sailed, and the ship’s master, failed to recognize the need to take any extra precautions or even consider delaying the ship’s departure given the foggy conditions that morning
• The master claimed not to know that his ship was headed in the direction of the Delta Tower because he allegedly did not know how the pilot intended to direct the ship through the Bay Bridge as it departed its berth in Oakland
• VTS failed to give a warning that the Cosco Busan was heading toward the Delta Tower of the Bay Bridge.  Had a warning been given even within the last minute or so, the ship could have safely traveled through the Charlie-Delta span;
• VTS failed to follow its standing orders and mission statement to “coordinate the safe and efficient transit of vessels in San Francisco Bay in an effort to prevent accidents” by either making recommendations or issuing directions “to control the movement of vessels in order to [protect] . . . the environment

A STATEMENT FROM JOHN COTA

Following sentencing, John Cota issued the following statement through his legal team:

Today marks the first time in over 200 years of maritime history of the United States that the government has sent a Bar Pilot to prison for an accident.

Captain John Cota, a man who literally grew up on the San Francisco Bay, is devastated by the events of November 7, 2007.   Having spent over 27 years as a Bar Pilot, and having worked on the waterfront since he was 12, Captain Cota is deeply tied to the Bay.  For the rest of his life, Captain Cota will bear the stigma of his role in the November 7, 2007 oil spill.

Captain Cota apologizes for his actions.

Sending a hardworking man to prison, who was just trying to do his job, for errors in judgment, is a very tough life lesson that Captain Cota wishes on no one.

Captain Cota hopes people understand that many factors – not just his actions – contributed to the cause of this tragic event.  Yet, he alone has been singled out for prosecution, and he alone will be going to prison.

Captain Cota accepts his share of responsibility.  But for lessons to be learned and carried forward to prevent this type of incident from ever occurring again – the multiple errors of all involved must be recognized.  To date, this has not been done.  Even the NTSB investigation was woefully inadequate and missed key evidence and critical facts.

The ship’s managers share in the responsibility for this accident by having:

• Allowed an unseaworthy ship to sail, with a vessel manned by a poorly-trained crew, supervised by an incompetent master; and
• Generated false documents after the accident to cover up its misdeeds.

The United States Coast Guard Vessel Traffic Service (“VTS”) also shares in the responsibility for this accident.  VTS made the conscious decision not to warn the Cosco Busan that it was heading straight for the Bay Bridge Tower in the fog.

It is baffling why these vessel traffic professionals sat silent in their control tower and did nothing to try to keep this tragic accident from happening.  There is persuasive expert opinion that there was ample time for VTS to warn, and had it done so, even within the last minute or so, there was still time for the ship to avoid hitting the bridge. The government must review its own procedures, in addition to prosecuting others, to make sure we never have a similar incident in the future.

In the end, Captain Cota hopes that this process is not just about blaming and punishing one man, but about finding solutions to making the Bay a safer place.  Captain Cota appreciates the support he has received from family and friends.

DOES ALL THIS AFFECT UK PILOTS?

What happens in the USA inevitably sets a precedent for court cases here in the UK so the answer is yes and the only way that any pilot can defend himself is to ensure that procedures, especially the Master / pilot exchange are as comprehensive as possible. Can’t be bothered? Take careful note of the following court statement:

Where it is possible to guard against a foreseeable risk, which, though perhaps not great, nevertheless cannot be called remote or fanciful, by adopting a means, which involves little difficulty or expense, the failure to adopt such means will in general be negligent.

As Australian pilot and senior IMPA Vice president observes:

The primary defence against negligence claims is “due diligence.” This really means that a reasonable person (in the eyes of a court) in the same position would have undertaken certain procedures and processes to ensure whatever it is that did happen, on the balance of probabilities, shouldn’t have happened.

This means that the courts could ask, “what could have guarded against the risk of the accident occurring?“. The answer is, “A proper Master / Pilot exchange  including a passage plan with contingencies that would enable a shared mental model by the bridge team (what we all know as BRM).” To which the courts could then ask the following question, “how much does it cost to have a proper MPX and produce a passage plan?”…..to which the answer is, “two minutes of time and about 20 cents for a sheet of paper”

AND FINALLY….

Just in case you still doubt that criminalization of pilots is just something that happens in the USA, the following has been received from EMPA:

On 1st August 2004 Capt Calvi boarded the Cruise Ferry ‘Danielle Casanova’

to help the Captain berthing in Marseilles harbour.  Due to sudden weather

changes and the constriction of the area the ship hit a pontoon with a

residual speed (less than ½ knot), after avoiding a collision with another

ferry and dropping an emergency anchor.  Unfortunately there were passengers

boarding another ferry moored on the opposite side of the pontoon.  During

the collision, the pontoon chains were broken and a car fell into the water

resulting in one fatality. After many years of investigation Captain Calvi

is facing charges for his conduct and he is now involved in a criminal

prosecution, together with the Ferry’s Captain, Gérard Bouvier.

JCB

The full NTSB report can be downloaded from:

www.ntsb.gov/publictn/2009/MAR0901.pdf

In fog. proceed with caution and obey the COLREGS!                                   Photo: MAIB

Fog has always been one of the elements to cause most concern to the mariner, especially in coastal waters, and in the days before radar the prudent navigator would frequently stop or anchor and wait until the fog cleared before continuing on passage. Similarly, once in pilotage waters, pilots would also anchor and await clearer visibility rather than risk a collision or grounding by continuing on passage. The advent of radar enabled vessels to proceed in fog and, as watchkeepers became familiar with using it, vessels were able to maintain schedules and then commercial pressures to proceed at full speed regardless of the visibility inevitably impinged upon safety. A series of fog related disasters led to new Collision Regulations (COLREGS) which dramatically reduced collisions and groundings in fog and these fog rules are also applicable in pilotage waters. As radar and GPS technology improved and with VTS able to provide traffic overviews, the primary limiting factor became the ability of tugs to manoeuvre vessels but although vessels requiring tug assistance were unable to proceed, other vessels continued to navigate normally in order to maintain schedules. The very nature of pilotage waters results in reduced safety parameters and these are obviously further eroded in fog. Four MAIB investigations have taken place during the last three years into fog related incidents, one of which resulted in a tragic loss of three lives and so all pilots would be well advised to read the full reports and take careful note of the findings.

The following are the “synopsis” and “conclusions” from the MAIB reports. The relevant sections within the full text are shown in brackets.

SKAGEN & SAMSKIP COURIER

Read the full MAIB report HERE

In June 2006, the general cargo ship Skagern and the container ship Samskip Courier collided in the Humber estuary in dense fog. Samskip Courier sustained minor damage to her bow but Skagern was extensively damaged forward and required major repairs.

Skagern had embarked her pilot Spurn light float and following the master/pilot exchange the vessel proceeded inbound towards King George Dock, Hull at a speed of 11.5 kts.

Samskip Courier had embarked a pilot at King George Dock, and after leaving the dock proceeded seaward at speeds of up to 12.5kts, in thick fog.

Both pilots were experienced and aware that the vessels would meet each other at some point; they had talked to each other on mobile telephones, and VTS also informed them of each other’s location. The vessels acquired each other on radar when some 2 miles apart but neither vessel plotted the other on radar as they converged.

VHF radio communications between the two pilots, together with the radar images, revealed that the vessels were on a collision course. The subsequent attempts at emergency avoidance were unsuccessful, and the ships collided head-on.

The ensuing MAIB investigation identified contributing factors to the accident which included:

• Failure to apply long established collision avoidance methods by the masters and pilots of both vessels.

• Pilot /master relationships: the masters’ over reliance on the pilots.

• Poor interaction and communications among the bridge teams.

• Loss of situational awareness by Samskip Courier’s pilot.

• The positioning of Sand End light float.

• Use of mobile telephones on the bridge.

Tracks of Samskip Courier & Skagen prior to the collision                               MAIB

CONCLUSIONS

3.1 SAFETY ISSUES

1. Humber Estuary Services’(HES) Port and Vessel Information System (PAVIS) recorded erroneous information about the master of Samskip Courier’s PEC status. [2.6]

2. Neither master exercised his right to take the con of their ships when it became apparent that a serious situation was developing. This was due to a misplaced trust in the pilots’ experience and ability. [2.8]

3. The bridge manning levels on both vessels were inadequate for the prevailing circumstances and conditions. There was little guidance given on watch manning levels in Samskip Courier’s BPM. [2.9]

4. Neither pilot queried the bridge manning levels on their respective vessels.[2.9]

5. Masters frequently take the opportunity to relax their vigilance when they have a pilot on board. [2.9]

6. Bridge team management was weak on both ships. No briefing or discussion of individual’s roles took place after the pilots boarded. [2.10]

7. Both pilots took over the con of their respective vessels without any formal andover taking place. [2.10]

8. The pilot master exchange on Samskip Courier was inadequate with neither the pilot or master giving each other enough information. [2.10] [2.11]

9. There was poor bridge teamwork and interaction, more so on Samskip Courier, culminating in a failure of the groups to operate as a team and in particular, monitor and question the actions of the pilots. [2.10]

10. There were repeated failures of key personnel to communicate with each other throughout. This impinged upon bridge team interaction. [2.11]

11. VHF radio familiarisation did not take place on Samskip Courier despite there being adequate time to do so whilst the ship was in the lock. This ultimately led to the pilot losing situational awareness at a crucial time. [2.12]

12. Pilots’ mobile telephones were used as the means of communication between the two vessels before and after the accident, resulting in the masters being excluded from the information exchange regarding their own ships. [2.13]

13. There was a failure to apply established collision avoidance measures by the pilots and masters of both vessels, namely:

• The vessels were travelling at an unsafe speed for the prevailing circumstances and conditions.

• There was a failure to determine early risk of collision by using systematic radar plotting or long range scanning techniques.

• Evasive actions to avoid collision were inadequate.

• Samskip Courier strayed from her side of the channel

• Accepted radar navigation principles for the prevailing circumstances were not applied.

• Restricted visibility sound signals were not used despite the prevailing conditions. [2.14]

14. The excessive speeds were possibly indicative of complacency through habitual risk-taking and a failure to perceive approaching danger. [2.15]

15. The vessels were steered from buoy to buoy using radar as the primary means of navigation without applying parallel indexing, long range scanning or clearing bearings. [2.17]

16. Positional information was not queried or relayed by the master of Samskip Courier to the pilot. [2.17]

17. Samskip Courier’s radar had a mapping facility which, if used appropriately, would have helped maintain situational awareness and possibly prevent the accident. [2.17]

18. Sand End light float was not best placed to indicate the proximities of the navigational channel. [2.18]

19. Both masters and pilots failed to take positive decisive action when it became apparent a serious situation had developed. [2.19]

20. The ship masters did not verbally query the actions of their pilots thus interfering with the process of them taking the con away from the pilots. [2.19]

21. The pilot of Samskip Courier misjudged the effect the tide and consequentially kept too far to Skagern’s side of the channel. [2.20]

22. Samskip Courier did not standby the stricken vessel, Skagern, until other assistance arrived. [2.21]57

RECOMMENDATIONS

The Port Marine Safety Code Steering Group is recommended to:

2007/121 Promulgate to pilots, by way of Port Authorities, a reminder on the importance of abiding by the International Collision Regulations at all times, and in particular Rule 6, Safe Speed, when navigating in confined waters in restricted visibility.

2007/122 Promulgate to Port Authorities the need for pilots to maintain dialogue with the bridge team regarding the conduct and execution of the passage plan, thus ensuring the team is kept fully involved, and informed, at all times.

2007/123 Highlight to Port Authorities the risks in using mobile telephones for passing operational information. They should emphasise the need for pilots to use mobile telephones only under controlled situations, and avoid the exchange of operational information which should more appropriately be transmitted by radio.

ABP Humber Estuary Services is recommended to:

2007/124 Discourage its pilots from using mobile telephones for discussing operational matters pertinent to the safe navigation of vessels when VHF radio is available.

The International Chamber of Shipping is recommended to:

2007/125 Through its member organisations, emphasise the need for shipowners to ensure masters are given clear guidelines which detail the importance of effective dialogue with pilots, and identifies the need for masters to challenge or question decisions or actions taken by pilots at an early stage so that, when required, effective corrective action can be taken to prevent accidents.

SEA EXPRESS & ALASKA RAINBOW

www.maib.gov.uk/cms_resources/Sea%20Express%201_Alaska%20Rainbow.pdf

SYNOPSIS

At 1138 (UTC) on 3 February 2007, the high speed ferry Sea Express 1 and the general cargo vessel Alaska Rainbow collided on the River Mersey in thick fog. The collision holed the starboard hull of the ferry, causing her to list and trim significantly within seconds. Alaska Rainbow was bound for Birkenhead Docks. Two tugs were attached before the vessel arrived off the lock. Here, the pilot turned the vessel to stem the tide and await the scheduled docking time, and for the visibility to clear enough for a safe approach to be made.

Sea Express 1 was bound for Liverpool Landing Stage. At 1033, as Sea Express 1 approached the Bar Light Buoy, the trainee captain made contact with Mersey Radio (VTS), who passed the positions of other traffic and advice that visibility in the river was poor. No mention was made of Alaska Rainbow.

Sea Express 1 proceeded inwards, reducing her speed over the ground to about 7 knots. At 1138, in the vicinity of Alfred Lock, Sea Express 1 took action to avoid Alaska Rainbow’s forward tug, which had suddenly appeared out of the fog directly ahead. Seconds later Alaska Rainbow appeared, and Sea Express 1 took further avoiding action. However, this was too late, and Sea Express 1’s starboard quarter and Alaska Rainbow’s bow collided. The collision tore a large hole in the starboard hull of Sea Express 1, immediately flooding the engine room and jet pump room effectively disabling the vessel. Sea Express 1 was towed to the Liverpool Landing Stage, where the passengers were disembarked.

Mersey Docks and Harbour Company (MDHC) and Isle of Man Steam Packet Company Limited (IMSPCL) have taken a number of actions following the accident, particularly with respect to VTS operations, pilotage training and the allocation of bridge team duties in preparation for type rating examinations.

Sea Express 1 being towed to the Liverpool Landing Stage                             Photo: MAIB

Conclusions

Factors related to Sea Express 1:

-A ground stabilised radar display was not used in the confined waters of a river transit, thereby making it difficult for the operator to distinguish moving targets from land radar returns. [2.2.1]

-The initial communication made by Sea Express 1’s captain to VTS lacked urgency and detail as to the seriousness of the situation, thereby delaying an appropriate external emergency response. [2.5.5]

-The allocation of bridge team duties in preparation for the type rating examination was unclear, resulting in the presence of other vessels in the vicinity to be missed during the period immediately leading up to the collision. [2.2.1] [2.2.2] [2.2.3]

Factors related to Alaska Rainbow:

-The pilot did not proactively communicate with Sea Express 1 and VTS at an early stage to ensure that all parties were aware of the hazard that Alaska Rainbow presented to other traffic, resulting unnecessarily in the development of a close quarters situation. [2.3.1]

-The pilot was not proactive in requiring support, and neither the master nor the OOW was proactive in providing support to the pilot, thereby unnecessarily increasing the pilot’s workload. [2.3.3]

-Neither the pilot nor the master ordered fog signals to be sounded, thereby omitting a means by which Sea Express 1 might have been alerted to the presence of Alaska Rainbow. [2.2.2]

-The pilot was insufficiently practiced in maintaining Alaska Rainbow’s position in the prevailing circumstances, resulting in the vessel moving significantly between the west bank and mid-river. [2.3.2]

Factors related to the VTS station:

-No fog routine was in place, thereby preventing a closer watch on vessel movements being maintained to ensure safe traffic flow at times of restricted visibility. [2.4.3] [2.4.4]

-The VTS duty staff were expected to absorb the additional workload that operation in restricted visibility demands; an independent audit of the Port of Liverpool’s safety management system might have identified this shortfall. [2.4.5]

-A review of the Mersey Channel Collision Rules on the sound signals required of vessels manoeuvring in close proximity during periods of restricted visibility would appear to be appropriate. [2.2.2]

-The VTSOs were not proactive in ascertaining further information following the initial report of the collision and in notifying Liverpool Coastguard, thereby delaying an appropriate emergency response. [2.5.4] [2.5.5]

-Additional workload created by the VTSOs having to take pilotage bookings at a time when performance of their normal duties was at a peak, had the potential to result in the VTSO responsible for the Information Service becoming distracted. [2.4.2]

-Specific risks associated with the carriage of passengers had not been separately assessed, particularly with regard to emergency response. [2.5.4]

RECOMMENDATIONS

The Isle of Man Steam Packet Company Limited is recommended to:

2007/185 Review its Safety Management System with particular respect to:

• using ground stabilised radar display in the confined waters of a river transit;

• improving external communications in the event of an emergency in terms of urgency and detail.

2007/186 Ensure that the passenger safety instruction card illustrates the lifejacket to be found under the seat for which the card is provided.

J.G.Goumas (Shipping) Co. S.A. is recommended to:

2007/187 Ensure its masters are given clear guidelines which detail the importance of effective dialogue with pilots and identify the need for the ship’s bridge team to:

• be proactive in providing support to pilots;

• challenge decisions or actions taken by pilots at an early stage so that, when required, effective corrective action can be taken to prevent accidents.

Mersey Docks and Harbour Company is recommended to:

2007/188 Complete its review of compliance with the requirements of the PMSC with particular reference to:

• VTS operations, ensuring that an effective fog routine is established and that the VTS station is sufficiently manned to absorb the additional workload that operation in restricted visibility demands, and that VTSOs are proactive in ascertaining further information in the event of incident;

• Pilotage best practice, highlighting the need for pilots to proactively communicate with approaching vessels and VTS at an early stage to avoid unnecessary development of a close quarters situation; to be proactive in requiring support from the ship’s bridge team; and to sound appropriate fog signals in restricted visibility.

2007/189 Following satisfactory completion of its review into PMSC compliance, invite the MCA to conduct a PMSC verification visit to the Port of Liverpool.

2007/190 Review the Mersey Channel Collision Rules with respect to sound signals required by vessels manoeuvring in close proximity during periods of restricted visibility.

AUDACITY & LEONIS

www.maib.gov.uk/cms_resources/Audacity_Leonis.pdf

SYNOPSIS

At 1351 on 14 April 2007, the UK registered product tanker Audacity was involved in a collision with the Panama registered general cargo ship Leonis, in very poor visibility, in the precautionary area at the entrance to the River Humber. Both vessels sustained damage to their bows. Fortunately there were no injuries and no pollution was caused. Audacity had been outward bound from Immingham Oil Terminal and was approaching the precautionary area in order to disembark her pilot. Leonis had entered the precautionary area from seaward and had just completed embarking her pilot. The MAIB investigation found that the operation of the bridge team on Audacity was inadequate, and the extent of the VTS area and VTS powers was not clearly understood by the VTS operators. The investigation identified contributing factors to the accident; these included:

• The pilots and bridge teams, on both vessels, did not make a full assessment of the

risk of collision.

• VTS procedures for managing traffic in the precautionary area were insufficient.

• VTS operators were unaware of the poor visibility in parts of the VTS area.

• Humber VTS did not have a formal operating procedure for periods of reduced visibility.

• Communications were poor.

• The Port Authority misunderstood how risk assessment could be used to improve the effectiveness of the VTS operations. As a result of this accident, Associated British Ports Humber Estuary Services (ABP HES) has taken several actions to improve the performance of the VTS, pilots and pilot boarding operations.

The VTS view showing a dangerous situation developing                                        Photo: MAIB

Safety issues directly contributing to the accident which have resulted in recommendations

1. The procedure for a pilot/coxswain briefing prior to embarking the vessel was

not conducted efficiently. The radar equipment available in the launch was liable

to severe shadow effect while close to vessels, making the identification of navigational markers unreliable. [2.11]

Other safety issues identified during the investigation also leading to recommendations

1. From historical data, incidents in the Humber Estuary are occurring more frequently than weighted in their current risk matrix. This indicates the risk is greater than initially allowed for or that the safety barriers are insufficient or ineffective. [2.3 / 2.5.2]

2. There were no detailed marine policies applied throughout the group, which made the auditing of ports within the ABP group for compliance with the PMSC more difficult. [2.5.1]

3. Risk analysis should be reviewed as a matter of routine after any serious incident to ensure the effectiveness of the safety barriers or to evaluate the need for additional barriers. [2.5.1]

Safety issues identified during the investigation which have

not resulted in recommendations but have been addressed

1. Due to a combination of circumstances the VTS operator allowed Leonis to drift into a dangerous position close to the exit from the outbound TSS. This action was compounded by the lack of traffic information to either Leonis or Audacity about the position of the other. [2.10.1 / 2.10.4]

2. Main Highway’s transit of the precautionary area, at speed, and with substantial alterations of course during the pilot boarding operation, was not good seamanship, nor was it commented on by VTS. [2.8.1]

3. The powers of the AHM to give advice and guidance to vessels operating inside the VTS area, but outside the port limits, were not fully understood, and there was reluctance for operators to issue proactive information to vessels within the precautionary area. [2.6.1 / 2.10.1]

4. It was incumbent on VTS to ensure that its plan for boarding of pilots recognized the need for vessels arriving at the boarding area to be properly separated both geographically and in time. [2.6.2]

5. The VDR recording from Leonis was incomplete, and information regarding helm and engine status was not recorded. There were no procedures in the SMS for the use and maintenance of VDR equipment. [2.4]

36

6. Routine information broadcasts, including visibility reports, were made every 2

hours. Although several reports of reduced visibility were received, no formal re-assessment was made of the visibility in the estuary and no additional broadcasts were made. There were no formal reduced visibility procedures and no requirements for reduced visibility to be reported. [2.6.2]

7. Humber VTS had no formal procedures for the preservation of records in the event of an incident. [2.6.3]

8. Leonis altered course towards the northwest because both master and pilot were unaware of the presence of Audacity. As a result, no assessment of the risk of collision was made before manoeuvring. [2.7.1 / 2.7.4]

9. ARPA was not used effectively on either vessel to assess risk of collision. By the time the ARPA was used on Leonis, it was too late for it to provide reliable information. [2.7.4 / 2.9.5]

10. Effectively, no-one held the con on the bridge of Audacity because both the master and pilot had deferred to the other, there was no discussion or questioning of the intentions of Leonis, and at a critical time they involved themselves with tasks that were inappropriate given the impending close quarters situation.

[2.9.1 / 2.9.2]

11. The bridge on Audacity was insufficiently manned in the circumstances and conditions. It did not comply with company requirements or HES instructions to pilots, however no additional resources were requested by the pilot. [2.9.2]

12. Despite advising the pilot of Leonis that he would take action and come to the south, the pilot of Audacity did not alter course. This lack of action was not questioned by the master or the VTS operator, and the pilot of Audacity did not advise Leonis’s pilot that he no longer intended to act as agreed. [2.9.2 / 2.10.3]

13. The communication between all parties involved was unclear and prone to misunderstanding, and use of standard marine phrases was not practised. [2.10]

14. VTS operators did not consider they were able to give advice and guidance to vessels with pilots on board. It was considered that the pilot would know what he was doing and that the operator did not need to be further involved once a pilot was on board. [2.10.2]

15. Communications from the VTS operator and P/L Venus were ambiguous and confusing. They were not result orientated and did not use identifier markers. Requests for specific information were inappropriately answered. [2.10.5 / 2.11]

Recommendations

UK Major Ports Group and British Ports Association are recommended to:

2008/103 Inform their members of the MAIB’s advice that they should consider how best to review how pilots can be helped to gain proper orientation of the traffic and navigational situation prior to boarding vessels to conduct acts of pilotage.

Associated British Ports Group is recommended to:

2008/104 Develop Group Marine Policies covering headline issues which can be implemented throughout the ports within the Group. Such policies should encompass, but not be limited to, training, risk assessment, and development and promulgation of best practice.

2008/105 Develop an auditing process to verify compliance with the group marine policies, including procedures which track the status of audit findings until agreed

corrective actions have been implemented.

LOSS OF TUG FLYING PHANTOM WHILST TOWING THE RED JASMINE IN FOG.

www.maib.gov.uk/cms_resources/Flying%20Phantom.pdf

SYNOPSIS

On 19 December 2007, the tug Flying Phantom was girted and sank while acting as a bow tug. She was assisting the bulk carrier Red Jasmine during a transit of the River Clyde in thick fog. Three of the tug’s four crew were lost; only the mate managed to escape from the tug’s wheelhouse and was subsequently rescued.

After Flying Phantom’s tow line had parted during the capsize, the pilot on board Red Jasmine completed the transit to the berth safely, in the thick fog, with only a stern tug to assist him.

The investigation has identified a number of factors which contributed to the accident,

including:

• The emergency release system for the towing winch on board Flying Phantom had operated, but not quickly enough to prevent the tug from capsizing.

• There were no defined operational limits or procedures for the tug operators when assisting/towing in restricted visibility.

• The routine observed by the tug’s crew prior to towing or entering fog was ineffective, resulting in the watertight engine room door being left open and the crew not being used in the most effective manner once the fog was encountered.

• The port risk assessment was poor, and the few control measures that had been put in place after a previous similar serious accident in thick fog proved ineffective.

• The port’s reliance on their ISO9001 quality management system audits to highlight safety concerns was fatally flawed.

• The lack of an individual to fulfil the role of “designated person” had resulted in major shortcomings in the port’s safety management system being overlooked.

• UK ports appear to have been failing to learn lessons from accidents at other ports.

• The lack of an accepted international industry standard for tug tow line emergency release systems.

CONCLUSIONS

Safety issues directly contributing to the accident which

have resulted in recommendations

1. Although the tow line emergency release mechanism operated after the mate activated the system, it did not act quickly enough to prevent the girting of Flying

Phantom. [2.4.1].

2. Towing winches are not generally regarded as equipment that should be the subject of class surveys. Additionally, there is no clear standard defining the time or loading within which the towing winch brake should release. [2.4.3]

3. There were no defined limits for tug towing operations in restricted visibility. If fog was encountered, there was no appropriate procedure or training provided to ensure tug crews could continue to operate safely. [2.5]

4. In the event of encountering fog, the bridge ergonomics of Flying Phantom were not suited to conducting blind pilotage operations. [2.5]

5. There were no formal pre-towing checks to ensure the necessary preparations had been completed prior to towing. This resulted in the engine room watertight door being open, which reduced the tug’s residual stability and, therefore, her ability to right herself when experiencing a heeling load. [2.6.1]

6. Once Flying Phantom had entered the fog bank, her personnel were not used to best advantage to ensure the vessel navigated safely in the narrow confines of the

River Clyde. [2.6.2]

7. Clydeport had no effective system for assessing the risk of fog. Although the area in which the accident occurred was known to be susceptible to fog, there was no reliable means of detecting the arrival of fog on the River Clyde, or warning river users of its presence. [2.7.3]

8. While a procedure for operating in restricted visibility was provided in the port’s safety management system, it was ineffective. Specifically, although a lay-by berth was detailed for consideration, it was not appropriate for a vessel of Red Jasmine’s size, and the pilot had little choice other than to continue to the ship’s intended destination, at Shieldhall Riverside Quay [2.7.4]

9. Clydeport’s risk assessment was immature, and many of the control and counter measures put in place were ineffective. It is vital that a comprehensive review of the port’s risk assessment is conducted urgently by an independent marine expert to rectify this position. [2.8.1]

10. Many of the recommendations from the Abu Agila accident, which occurred in thick fog, were not followed up, and the subsequent control measures were not implemented or were ineffective. [2.8.2]

11. There were a number of inconsistencies and conflicts within Clydeport’s SMS documentation. These had the potential to cause confusion and permitted too much flexibility in interpretation. [2.8.3]

12. Clydeport’s ISO9001 audits were not effective at highlighting any gaps in safety procedures or the adequacy of the safety procedures in place. Furthermore, the audit approach did not provide a means of checking that the underpinning risk assessments were adequate. [2.8.4]

13. Clydeport’s board was receiving a false impression of the safety performance of the port by relying on the ISO9001 system acting as the designated person. Given the safety management system shortcomings identified in this investigation, it is considered essential that Clydeport needs to appoint an appropriately qualified individual to the post of designated person under the Port Marine Safety Code. [2.8.5]

Safety issues identified during the investigation which have

not resulted in recommendations but have been addressed

1. The liferaft painter was attached to the tug directly without a weak link. Although having no bearing on this accident, if Flying Phantom had been lost in deeper water, the liferaft, even if it had inflated, would have been lost with the tug. [1.7.7]

2. Lessons from an accident at one port are not always being learnt by other. [2.9]

Recommendations

Clydeport Ltd is recommended to:

2008/161 Appoint an appropriately qualified individual to the post of designated person under the Port Marine Safety Code.

2008/162 Conduct an urgent review of its port risk assessment and safety management system to ensure:

• Requirements, conditions, controls and operational limitations for the safe transit of large vessels on the Clyde are clearly defined.

• Ambiguities or conflicts within its SMS documentation are removed.

• The company’s SMS is subject to routine audits by an independent and appropriately qualified marine professional.

• Limitations and/or working procedures relating to the operation of tugs in restricted visibility are agreed with the port tug operators and incorporated into standard operating procedures.

Lloyd’s Register is recommended to:

2008/163 Take forward a proposal to IACS to develop a standard for tug tow line winch emergency release systems, to ensure tow lines can be released effectively when under significant loads in an emergency.

Svitzer Marine Ltd. in association with the BTA is recommended to:

2008/164 Derive limitations and associated necessary guidelines and training for the operation of tugs in restricted visibility. Ensure that ports and pilots are aware of such limitations and guidelines.

The British Tugowners Association is recommended to:

2008/165 Highlight to its members the importance of tug crews’ emergency preparedness, including:

• maintaining watertight integrity

• functionality of tow line emergency release systems

• limitations and procedures for operating in restricted visibility

Although it occurred in the USA, the Cosco Busan allision with the Bay Bridge in San Francisco will inevitably have relevance to pilotage over here. There is also relevance to this quarter’s feature on piloting in fog.

At the time of writing the official National Transportation Safety Board (NTSB)  which is the USA’s equivalent of the MAIB, had still to publish the full results of their enquiry into the incident but they have issued a preliminary report which identified failures in procedures and communication similar to those identified by the MAIB in the feature.  The key findings are as follows:

M/V Cosco Busan left its berth in the Port of Oakland in thick fog. The San Francisco Bay pilot issued directions that resulted in the ship striking the fendering system at the base of the Delta tower, which created a 212-foot-long gash in the ship’s forward port side and breached two fuel tanks and a ballast tank.

As a result of the allision, over 53,000 (US) gallons (approx. 220 tonnes) of fuel oil were released into the Bay, contaminating about 26 miles of shoreline and killing more than 2,500 birds of about 50 species. Total monetary damages were estimated to be $2 million for the ship, $1.5 million for the bridge, and more than $70 million for environmental cleanup.

In its determination of probable cause, the NTSB cited three factors:

1) The pilot’s degraded cognitive performance due to his use of impairing prescription medications.

2) The lack of a comprehensive pre-departure master/pilot exchange and a lack of effective communication between the pilot and the master during the short voyage; and

3) The master’s ineffective oversight of the pilot’s performance and the vessel’s progress.

The NTSB recommended that the U.S. Coast Guard:

1) Ask the International Maritime Organization to address cultural and language differences in its bridge resource management curricula.

2) Revise policies to ensure that, in its radio communications, the Vessel Traffic Service (VTS) identifies the vessel, not only the pilot.

3) Provide guidance to VTS personnel that defines when their authority to direct or control vessel movement should be exercised.

4) Require mariners to report any substantive changes in their health or medication use that occur between required medical evaluations.

5) Ensure that pilot oversight organizations share relevant performance and safety data with each other, including best practices.

The NTSB also recommended that the American Pilots’ Association remind its members of the value and importance of a verbal master/pilot exchange, and encourage its pilots to include the master in all discussions involving the navigation through pilotage waters.

What is different in this case and potentially of most concern to all pilots is that in response to the media (supposedly representing public opinion) outcry someone has had to be identified to take the blame and so the hapless pilot has had, not just his actions on that day, but also his whole career and personal lifestyle examined in microscopic detail in a search for culpability. This detailed examination of one individual discovered that the pilot had been involved in previous incidents and that at the time of the allision with the bridge he had been taking medication, which may have affected his performance as a pilot. With all this attention upon him it is hardly surprising that the pilot voluntarily surrendered his authorisations at an early stage.

Despite this prompt action pending the outcome of the enquiry the pilot faced two criminal charges under the “Clean Water and the Oil Pollution Act” (CWOPA) and the “Migratory Bird Treaty Act” (MBTA).  All pilots should carefully note the following charges levelled against him:

That the pilot, John Cota under the CWOPA:  “did negligently cause the discharge of oil in such quantities as may be harmful from a vessel, the Cosco Busan, into and upon the navigable waters of the United States, without a permit. Specifically, on or about November 7,2007, Defendant Cota, while piloting the Cosco Busan, caused approximately 58,000 gallons of heavy fuel oil to be discharged from the vessel into San Francisco Bay by acting in a negligent manner, that included the following:

(a) Failing to pilot a collision free course.

(b) Failing to adequately review with the Captain and crew of the Cosco Busan prior to departure the official navigational charts of the proposed course, the location of the San Francisco Bay aids to navigation, and the operation of the vessel’s navigational equipment.

(c) Departing port in heavy fog and then failing to proceed at a safe speed during the voyage despite limited visibility.

(d) Failing to use the vessel’s radar while making the final approach to the Bay Bridge.

(e) Failing to use positional fixes during the voyage; and failing to verify the vessel’s position vis-a-vis other established and recognized aids to navigation throughout the voyage”.

And under the MBTA: “without being permitted to do so by regulation as required by law, did take migratory Birds, including at least one Brown Pelican, Marbled Murrelet and Western Grebe.”

At the trial John Cota pleaded guilty to the charge of negligence admitting one count of negligently discharging a pollutant and one count of violating a federal law against killing migratory birds and will receive a sentence of two to 10 months in prison and a fine from $3,000 to $30,000.

Is this case relevant to the UK?

So far I as can ascertain the answer is yes and all pilots should remember that the £1,000 limitation of liability under S22 of the 1987 Act is not applicable to criminal charges. In similar circumstances over here a pilot involved in a Cosco Busan type incident could face similar pollution charges by the Environment Agency under the UK’s “Water Resources Act” & also under Section 21 of the 1987 Act.

I am an employed pilot so aren’t I covered by my employer’s insurance?

The answer here is most probably not because once on board and piloting any pilot, regardless of employment status is “an independent professional man who navigates the ship as a principal and not as a servant of his general employer” (Esso Bernica and Cavendish).

Am I covered for such an incident by the UKMPA insurance?

The answer here is that although we are covered for legal defence costs, which includes pollution, nobody can insure against a criminal act and the exclusion clause states: “the accident did not result from the insured’s intentional and willful violation of any Government statute, rule or regulation” ie if excessive speed in fog was proven?

You have been warned!

JCB

Earlier this year the Government produced the draft for a Marine Bill which, as well as introducing new legislation to cover the marine environment would also replace the 1987 Pilotage Act. Although we now understand that no Parliamentary time has been allocated for the passage of this Bill in the current legislative programme, the draft was put out to consultation and at the conference the DfT indicated that despite the probable lack of formal legislation, the DfT wished to incorporate the proposals into the Port Marine Safety Code as an interim measure pending parliamentary time for the Bill to be formally incorporated. The consultation process was therefore extremely important and I know that in addition to the UKMPA submission, many pilots submitted individual responses.
One area in particular was of deep concern to pilots and that was the inclusion within the draft of a proposal to remove the requirement for a PEC holder to be the “Bona Fide” Master or Mate of the vessel and to replace it with “any person”!
Ever since the implementation of the 1987 Act, pilots have been aware that the “Bona Fide” requirement was being seriously abused by many operators who quite openly transferred an existing PEC holder from one vessel to another which had no valid PEC holder on board. Another common abuse was for a regular trading ship to obtain one PEC and then to permit relieving Masters and Mates to use the same number, even though they may never have navigated in the port to which the PEC was valid!
Such abuse was exposed by incident investigations and occasionally by random checks or by the “Bona Fide” PEC holder reporting the scam to the relevant authorities. Despite this practice being against the law, the difficulties involved in proceeding with a prosecution coupled with a general lack of enthusiasm by CHA’s to prosecute important customers resulted in such abuse becoming common practice amongst some operators. The arguments put forward by the operators for amending this clause of the Bill is that on some trades, the requirements of the Working Time Directive introduce practical difficulties in ensuring that a bona fide officer is available to undertake the PEC role when required. Whilst it is possible to have some sympathy with this viewpoint, in practice the majority of vessels where this may potentially be a problem tend to be short sea traders and if there are insufficient PEC holders on board the vessel to adequately manage fatigue then the operator should either place additional officers on board or take a pilot. After all, the sole reason for establishing a compulsory pilotage district is safety.
The operators other  claim that the title of “First Mate” is now obsolete is total nonsense since any officer who holds the relevant certificate can be signed on the articles as a bona fide First Mate. Since the majority of officers on well run short sea traders have a Master’s certificate this argument is just a smokescreen. So why does all this matter? Well, anyone who may be in doubt as to how safety can be compromised by PEC abuse should read the MAIB report into the collision between the Ursine and Pride of Bruges in Hull in November 2007.The following is an extract from the MAIB synopsis of the full report.

Ursine was on her first voyage into Hull, having recently been chartered to undertake a service between Hull and Rotterdam.  In accordance with the terms of the charter party agreement, P&O had placed its representative on board to perform the pilotage duties for both ports. In accordance with local regulations the P&O representative, who held a Pilotage Exemption Certificate (PEC) for the river Humber, was on Ursine’s bridge with the vessel’s bridge team when the vessel entered the river. As Ursine approached Hull, the PEC holder gave a briefing to the rest of the bridge team on the approach and entry into the lock for King George Dock. The master, who was not experienced in handling ro-ro vessels, assumed that the PEC holder would be in control. However, the PEC holder, who was not an experienced ship handler, assumed that the master would take charge of the manoeuvre. Eventually, with both men involved in the ship handling, Ursine berthed in the lock. In the lock, the PEC holder and the master, who had not been to Hull before, discussed the required approach for berthing at the P&O terminal. Again, there was no clarification as to
who would be in control of the vessel. Once the lock had filled, Ursine proceeded stern first towards the berth, with both men handling the controls. From the conning position, on the port bridge wing, neither of them could see the P&O terminal. In the absence of any formal berth allocation, the PEC holder directed Ursine towards the berth which he assumed had been allocated to the vessel. This berth, 5 Quay Middle,
was adjacent to the one regularly used by Pride of Bruges. However, on this occasion, for operational reasons, Pride of Bruges had been berthed on 5 Quay Middle. In the confusing situation, during which key bridge team members found themselves undertaking tasks for which they were inadequately prepared, Ursine was manoeuvred stern first towards the berth already occupied by Pride of Bruges until contact was made between the two vessels.

The 1987 Pilotage Act states that only the bona fide Master or Mate of the vessel can apply for an exemption certificate, yet here we have a supernumerary placed on board “in accordance with the terms of the  charter party agreement” to circumvent the compulsory pilotage requirements of a port. Where’s the prosecution?
Policing and prosecutions regarding PEC abuse are the responsibility of the CHA and although evidence produced by an MAIB enquiry is inadmissible in a court of law their recommendations provide an indication as to where responsibility lies and what action may be required. This investigation produced the following recommendation:

Additionally, a recommendation has been made to the British Ports’ Association and UK Major Ports Group to promulgate to Competent Harbour Authorities the importance of ensuring candidates for PECs are bona fide masters or first mates, and of carefully assessing a candidate’s ship handling ability before a PEC is issued or vessels of particular types and sizes are added to existing certificates.

I have frequently piloted vessels chartered for a regular trade where the Master has started logging trips to obtain a PEC, not because he wants one but because he has been informed that it is apparently a condition of the charter party that he must obtain one! It was therefore with great interest that I read a “flyer” issued by the MAIB to the shipping industry which included the following recommendations regarding charter policy:

o    When appointing a representative to a time chartered vessel to perform the duties of a pilotage exemption certificate holder the charterer should ensure that the representative is sufficiently trained and experienced for the task.
o    When appointing senior officers to a vessel, the owner should ensure they have the necessary ship handling and bridge team management training and experience.
o    The charter party terms allowed for the representative to perform pilotage duties as a PEC holder, but did not stipulate that the representative must be bona fide the master or first mate of the vessel in accordance with the requirements of the Pilotage Act 1987, Chapter 21, Section 8.
o    When evaluating the suitability of a vessel for time charters, the charterer should consider the training and experience of the vessel’s key personnel, taking into account the customs and requirements of the trade concerned.

This is a very interesting document since it also places an onus on the charterer of a vessel to ensure that the PEC system isn’t being abused which effectively divides the responsibility for ensuring compliance with the law between the CHAs and the charterers. However, I’m sure that it is a pure coincidence that the intense lobbying by the ship operators to remove the term “bona fide” from the proposed Marine Bill intensified with the publication of this MAIB report!

The full report is available in printed form from the MAIB or can be downloaded from:

www.maib.gov.uk/cms_resources/Ursine_Pride of Bruges.pdf

JCB

Blame and shame is really just a wasted opportunity

By pure coincidence, at the same time as Dave Williamson wrote his thought provoking article (Pilots under siege?) a letter appeared in Lloyd’s List  written by IMPA Vice President and head of standards and training at the Australian Marine Pilots Association (AMPA), Steve Pelecanos which serves to underline the issues currently being debated by the UKMPA

Cosco Busan Pilot error or pilot support system failure?                  Photo KCBS website

THE United States of America is looked up to by many nations of the world as the epitome of democratic maturity — a nation that embodies the zenith of human evolution. A nation founded on the great ideals of Liberty, Equality and Fraternity and the pursuit of happiness is, after all, where any human being should expect to live and thrive in an environment where fairness permeates all facets of life. This is the stuff of leadership; an aspiration for many.

In the maritime context also, the US has had a great and proud history and has provided the world with leaders such as Nathaniel Bowditch, Thomas Sumner, Matthew Maury and writers of the calibre of Herman Melville and Henry Dana. More recently, Dominic Calicchio won international renown for his investigative work following the sinking of the Marine Electric.

However, on the morning of November 7, 2007, the reputation and image of a great maritime nation collapsed when the world witnessed the knee-jerk response of a bureaucracy to the collision between the MV Cosco Busan and San Francisco’s Bay Bridge.

The process initiated on that morning seemed focused on finding, not the root cause of the accident, but rather, a scapegoat — an individual upon whom to pin the blame; a process that seemed more guided by the philosophy, “if we remove the individual, we remove the problem”, rather than a philosophy of “what lessons can we learn to prevent this type of accident reoccurring?”.

The substantial body of evidence derived from research into accident causation reveals, quite clearly, that individuals are seldom the cause of accidents.

Most organisational accidents occur because proper defences are not put in place to prevent them.

In this, the role of management and the regulator cannot be overlooked and when they fail in their duty, it is normally the hapless individual at the coalface who they’ll pursue to blame and hang out to dry. They will rarely point the finger at their own failure.

And so it was for the pilot on the bridge of the Cosco Busan. Compare what happened to him with what happened to the pilot on the Zim Mexico.

Both accidents occurred in the same country, but the responses could not have been more different. In the former case, the crew of the Cosco Busan were granted total immunity from prosecution to help build the case against the pilot; in the case of the Zim Mexico the pilot carried on working and the ship’s master was arrested. Whatever happened to the presumption of innocence?

In the case of the Cosco Busan, the press has made a meal of the pilot’s medical and pilotage history but has left those who need to be questioned off the hook. Is the press informing the public or protecting the bureaucracy?

Pilotage is a very old profession and the law of pilotage is well established. The pilot is engaged as an adviser to the master. When a pilot arrives on the bridge of the ship, the words “vessel to master’s orders on pilot’s advice” are entered into the ship’s log book. In other words, the master is still responsible for his ship and the presence of the pilot does not relieve him of that responsibility. In San Francisco, the Harbours and Navigation Code expressly reinforces this principle of pilotage law. So why then, was the ship’s crew granted immunity?

In very general terms, the relationship between the ship’s master and the pilot is based on a sharing of knowledge — the pilot has local knowledge of his port’s geography and regulations and the master has knowledge of his ship and its equipment.

From what we read, the event that immediately preceded the accident was a misinterpretation of the information given by the ship’s electronic charts. The pilot relied on the master’s knowledge of the ship’s equipment. Prima facie, it appears that the master provided the pilot with the wrong information and it was this information upon which the pilot made a decision.

But this leads to even more questions. If the master could not provide the pilot with accurate information about the ship’s equipment, had the shipowner ensured, as required by international convention, that the master was properly trained in the use of the equipment?

These questions have not been asked. Nor has anyone asked why, if the pilot’s medical history was of concern, did he still hold a licence? And what standard operating procedures did the Pilot Association have in place regarding pilotage of vessels in fog? Were these procedures robust enough to deal with the circumstances? What measures of oversight did the regulator employ to ensure the Pilot Association had an effective safety management system in place? What measures of oversight did the Pilot Association employ to ensure its pilots adhered to its safety management system?

The old profession of pilotage has been undergoing significant change in recent years. As in all highly operational environments, safety in pilotage is systems based and all of those involved in the regulation, management and execution of pilotage safety sharing a responsibility to ensure the systems are robust and have the rigour to withstand the highest scrutiny.

It is so easy, and so wrong, to blame an individual for an accident of this kind. A proper accident investigation needs to delve deeply to find the root cause. It is only when we understand the root cause of accidents and take measures to address them that we move forward in creating a safer society for the human race. This is something that should be clearly understood and practiced by great democracies.

The way the case of the Cosco Busan is being prosecuted is a throwback to yesteryear where all the benefits that could flow from a modern investigation have been sacrificed in a spirit of vengeance. Blame and shame might provide momentary satisfaction for those with a warped sense of justice but, at the end of the day, it is simply a wasted opportunity.

Captain S. Pelecanos

Brisbane pilot and President, Australian Marine Pilots’ Association (AMPA), vice President IMPA

You will recall that in 2006 the APL Panama spent a 4 month Holiday on the beach off Port Ensenada in Mexico (Summer 2007 issue). Last September the news had obviously reached Maersk that beach holidays were available in Mexico because on September 1^st 2007, the 291m container vessel Maersk Diadema (ex Charlotte Wulff) ran aground on the approach to the Mexican port of Lazaro Cardenas. No pilot was aboard at the time of the incident.

From the Internet. Photographer unknown.

Although there are very few details concerning this incident, it would appear that the Maersk Diadema was inbound while another Maersk vessel was outbound. The outbound pilots were supposed to board Maersk Diadema and take her in but bad weather and the excessive speed of the vessel resulted in the vessel going aground on a sandbank before the pilot could board. Three local tugs were despatched to tow the ship off but were unable to do so. Titan Salvage were contracted by the German owners on 4^th September to refloat the vessel and successfully completed the salvage on 5^th September. Fortunately there were no casualties and no pollution.

At a time when pilots are under attack from many industry sectors for failing to integrate into the ship’s “bridge team” this is yet another incident that seems to confirm that when vessels are approaching pilot boarding areas, the bridge team seems to switch off in anticipation of his arrival. I (and I am sure the majority of you) have been horrified to see ships placing themselves at extreme peril by ceasing to navigate once they see the pilot cutter approaching. Just recently, one remarkably brave (stupid) Master decided to anchor his ship right on the pilot boarding “diamond”. This diamond is of course used as a waypoint in the GPS so vessels head straight for it. Although my vessel had been advised of the boarding heading to provide a lee, myself and the cutter crew watched in amazement as my vessel scraped past the anchored ship prior to altering course for the lee and the cutter crew informed me that they had witnessed several other ships do the same. The ship at anchor remained there for over 24 hours and it seems quite remarkable that no other vessel collided with it. Pilots are being blamed over “one person error” but the facts are that the navigation of some bridge teams is alarmingly incomprehensible! JCB

Read the full ATSB report www.atsb.gov.au/publications/investigation_reports/2006/MAIR/pdf/mair227_001.pdf

One of the first lessons I was taught when training to pilot VLCC’s onto Single Buoy Moorings in Nigeria was the importance of checking that the helmsman put the wheel over as ordered and not to be shy about even gesticulating with arm movements to reinforce the verbal command when issuing helm orders. My thoughts that Peter Snow type gesticulations on the bridge might make me look a bit foolish were dismissed by the training pilot with the observation that in view of the potentially adverse consequences of such an error, I would look rather more than foolish if the helmsman put the wheel over the wrong way! 25 years on, and although now piloting on the Thames, that lesson is still valid and is one that I now instil in new trainee pilots. It does seem strange that in the 21^st century, where technology is so dominant, such basic techniques can still have relevance but as every pilots knows it is not that uncommon for the helmsman to put the wheel over the wrong way and the consequences of such errors going undetected will invariably result in a grounding or collision in pilotage waters.

One such error brought the lesson firmly home last year when the woodchip carrier Crimson Mars grounded whilst departing from Port Dalrymple in Northern Tasmania. The approach channel to Port Dalrymple looks narrow and winding but the pilot had been working in the port for 13 years so was presumably well experienced in handling large ships in the channel. On this occasion the ship was proceeding at full manoeuvring speed into a flood tide which gave a speed over ground of about 10 kts. At a critical turn the pilot claimed that he ordered port 10 but the helmsman claims that he ordered starboard 10. Observing that the ship was not responding, the pilot thought that the flood tide was acting on the port bow thus reducing the effectiveness of the rudder and claims to have ordered port 20 closely followed by “hard to port”, again the helmsman recalled the order being starboard. Noticing that the vessel was now swinging to starboard the pilot checked the helm indicator and then noticed that the helm was hard to starboard. Although the engine was put full astern and the anchors were let go the vessel grounded shortly afterwards causing major damage to the bulbous bow.

The official report goes into detailed analysis of the events leading up to the grounding but it is evident that in common with many pilotage acts the pilot alone was ‘the bridge team” and since neither the Master nor the officer of the watch (OOW) recalled either the helm order given by the pilot or the acknowledgement by the helmsman it is obvious that the passage was not being monitored in accordance with “best practice” procedures! This accident happened in good visibility and in daylight and it is evident from the chart that, had anyone on the bridge been paying even minimum attention to the passage then with land to starboard, a reef a couple of cables right ahead and the channel to sea open on the port bow that a starboard helm order was probably not going to achieve much other than a disaster and this would therefore tend to support the pilot’s statement of helm orders and that the helmsman put the wheel over the wrong way. Investigators are always incredulous that such failures can occur on even well found vessels, pilots just reflect that “There but for the grace of fate go I”! Such is the reality of pilotage and this incident serves to confirm my own “Theorem of Pilotage” that the difference between a good pilotage manoeuvre and a bad pilotage manoeuvre is 10 seconds inattention and the difference between a successful pilotage act and a disastrous one is 20 seconds inattention!

As with all these investigations we should all learn lessons and returning to my introduction, the Australian investigators provide the following recommendation regarding helm orders, “They should also ensure that the conventions governing helm orders are observed, particularly the use of ‘midships’ when changing rudder direction, and ‘closing the loop’ when communicating orders to a helmsman. The use of hand signals to enhance the communication of helm orders should also be considered”.

As I understand it “closing the loop” refers not just to the established practice of the helmsman repeating the order back to the pilot but also the traditional best practice of confirming when the instruction has been executed.

The rudder angle indicator

The other key recommendation for pilots in the report is that “Pilots and masters should ensure that they are able to read, or otherwise be able to check, the rudder angle when conning a ship”.

This is a very significant recommendation in that it highlights once again the fact that new ships are still being constructed with appalling ergonomics which totally fail to provide an efficient navigation centre. Although only launched in 2002, the Crimson Mars had a “traditional” wheelhouse arrangement (see plan) virtually undistinguishable from those found in the 1960’s with the engine telegraph on one side of the bridge, the radars on the other and the helmsman in the middle. The instrumentation is also unchanged from the Japanese design of the1970’s with various pale green instrument readouts (will the stock never run out?!), including the helm indicator, sighted above the centre wheelhouse window directly above the pilot’s head at the normal conning position. All this reality is far removed from the utopian dream of the “e-navigation” proponents! Because of the cranes mounted on the centreline of the ship, the class rules for the Crimson Mars require two additional “conning” positions with a clear view forward and the pilot was conducting the ship from the starboard position adjacent to where the radars were sighted at the time of the incident. The report considers it significant that there was no helm indicator visible from this position stating that “If the incorrect use of starboard rudder had been observed earlier the grounding may have been prevented”. It goes on to note that

SOLAS, Chapter V, Regulation 12 states “… ships … shall be fitted with indicators showing the rudder angle, the rate of revolution of each propeller … All these indicators shall be readable from the conning position”. This would tend to suggest that the arrangement on board the Crimson Mars was not compliant. Not so, the report states the following with respect to this:

During the investigation Class NK ( The ship’s classification society Nippon Kaiji Kyokai)

advised the ATSB that they interpret this (SOLAS regulation)to mean that all indicators required by the provisions of the SOLAS regulation should also be readable from the ‘additional conning positions’. Class NK also stated that these positions are normally located approximately 2.5 m from the conning position which is usually on the centreline and that the indicators near the centreline are not difficult to read from such positions. They required additional indicators when additional conning positions were distant from the centreline such as on bridge wings.

The photo clearly reveals that this is not the case and as we all know, even at the centre line “conning position” if the pilot is standing in front of the window next to the compass repeater he cannot see the rudder indicator above his head without an awkward contortion risking serious neck dislocation.

Returning to the report it is evident that the ATSB is not convinced by the interpretation of the rules by Class NK but, as with most investigations, fails to actually condemn the interpretation (mustn’t make waves which might upset the status quo!). I have read it several times and can only conclude that it is non committal waffle. Perhaps someone more perceptive than me can decipher the meaning so I have reproduced the following relevant section directly from the report, grammatical errors included:

Extract from report section 2.3 Conning Position (Page16)

In submission ClassNK stated:

The aim of the additional conning position is “giving a clear view”. SOLAS Ch. V/12(m) is required the indicators shall be readable from the conning position. The conning position means centre conning position and is not including the additional conning positions. This is to clarify that it is not necessary to provide an additional rudder angle indicator and a shaft revolution indicator at each additional conning

position in accordance with NK rule, ISO standard and IMO MSC/Circ.982

under the SOLAS Convention.

The above, however, is only the interpretation by ClassNK of the SOLAS regulation.

The regulation does not state that it refers to a conning position on the centreline or

a primary conning position, nor implies secondary or additional conning positions

to which its requirements do not apply. It is also reasonable to interpret that the

requirements that apply to a conning position in the regulation apply to all conning

positions on a ship’s bridge.

The sign indicating the starboard additional conning position on the bridge of

Crimson Mars may have initially prompted the pilot to take this position in the

circumstances. When it became apparent that he could not read, in particular,

the rudder angle indicator he should have moved to a position in which he could

read it. The rudder angle indicator should be readable from a position taken while

conning a ship.

*****

So, as I understand it, the Class NK rules require that if the view through the bridge windows on the centre line is obstructed then two other conning positions with a “clear view” forward must be provided but ClassNK don’t believe that these require the rudder angle indicator to be readable. These secondary positions are indicated on the plan as positions A & E and the Crimson Mars also has these points formally marked with “Conning Pt” in red on the bridge front. SOLAS regulations require that the rudder angle indicator and engine revolution indicator “shall be readable” from a conning position. It therefore seems perfectly clear that the SOLAS regulations require that these two instruments must be readable from the secondary conning positions. However, this would obviously involve additional expense that will bankrupt the poor ship owner so the ATSB are seemingly suggesting that yes, these are the requirements but if the ship’s arrangement is non compliant then it is the pilot’s responsibility to undertake a bridge survey and identify an unofficial conning point where he has both a clear view forward and a view of the relevant instruments! What nonsense. In my opinion such poor ergonomics are totally unacceptable in the 21^st century and a valuable opportunity has been missed by this investigation to condemn such (regrettably all too popular) dysfunctional wheelhouse layouts as not “fit for purpose”.

Although unfamiliar with the Dalrymple port approach the chart indicates that it is a very narrow channel with tricky bends and manoeuvring would seem also to be compromised by the tides mentioned in the report. A small rudder angle repeater probably costs less than 20 and could easily be fitted at the additional conning points. I am in no doubt that had such a repeater been fitted as seemingly required by SOLAS regulations then the pilot would have been monitoring it and this grounding would have been avoided. The old saying of a “ship spoiled for the want of a h’apeth of tar” is, in my opinion, appropriate in this case.

I would like to believe that despite the lack of condemnation by the report, ClassNK and other Classification societies might realise the potential weakness of their arguments, learn the lessons and arrange for additional rudder angle repeaters to be fitted in order to ensure full compliance with SOLAS recommendations at the secondary designated conning positions. However, knowing how such issues are usually dealt with in the maritime world, I wouldn’t be at all surprised if the actual outcome will be for the Classification societies to arrange for the “conning pt” markings to be removed to avoid any potential liability. I hope to be proven wrong!

JCB

USE OF MOBILE PHONES

In the report relevance was attached to the fact that 6 minutes before the grounding the pilot had received a call on his mobile phone which he terminated after 23 seconds. Some publications reporting this grounding have wildly stated that the grounding was caused as a direct result of the mobile phone conversation but the records show that although the call was received just as the ship was approaching an earlier bend in the river, the pilot successfully negotiated that turn and correctly aligned the ship in anticipation of rounding the point where control was lost.. However the investigators did consider the mobile phone use to be of relevance in this case and referred to MGN 299 which includes the following recommendations regarding the potential for watchkeepers to be distracted by mobile phone conversations:

Interference, in this context, relates to the distraction caused by making or

receiving mobile phone calls at inappropriate times during the conduct of

the vessel’s navigation and conning.

Such activity is liable to demand the attention of bridge personnel when

full attention should be devoted to the safe and efficient navigation of the

vessel.

Consideration should also be given to prohibiting all mobile phone usage

when navigational requirements demand the individual attention of all those

responsible for the safe conduct of the vessel.

In this case the phone was used six minutes before the incident for a few seconds. Six minutes is a long time and I personally don’t believe that this call could have possibly have had any influence over the subsequent event but the report makes the following observations:

The pilot did not discuss the use of his mobile telephone with any of the bridge

team. The master stated that its use was inappropriate and that he was not sure if

the pilot was concentrating on the pilotage. The third mate believed that the master,

rather than he, should ‘challenge’ the pilot in such a case. In any event there was no

‘challenge’, increased vigilance, or any other action by the bridge team in response

to the use of the mobile telephone by the pilot.

The pilot stated:

I do not believe that the pilot’s mobile phone use before Salt Pan Point

contributed to the grounding at Long Tom Reef, nor do I believe that discrete

communications by mobile phone after the grounding negatively affected

the return of the vessel to anchor at Bell Bay.

The report responds thus:

While the pilot did not use his mobile telephone when he was giving the helm

orders leading to the grounding, he did so a few minutes before. Using a mobile

telephone causes a distraction and interferes with the attention of the user and

the entire bridge team. This distraction interrupts the thought processes and

concentration of the bridge team and is not restricted to just the periods that a

mobile telephone is used. In any event, there is overwhelming evidence in the

transport industry that the use of a mobile telephone by a person concurrently

with operating a transport vehicle is a distraction to the prime task of operating the

vehicle.

The ATSB investigation report number 162, the grounding of the container ship

Bunga Teratai Satu on 2 November 2000, concluded that the distraction caused

by the use of a mobile telephone was the significant unsafe act that resulted in the

grounding. The incident highlighted the distraction that mobile telephones can

cause to the user, as well as to others.

The use of mobile telephones is contrary to good BRM principles, hinders

situational awareness and prevents an optimal ‘state of the bridge’

You have been warned!! JCB

Vessels: Sunny Blossom, Arctic Ocean, Maritime Lady

Last December the MAIB released a report into a collision, subsequent sinking followed by another collision of the entrance to the Kiel Kanal off Brunsbuttel, all under the Elbe VTS control tower. In my opinion this particular MAIB report is of interest to pilots in that I believe that it is the first report to examine the roles of a vessel excluded from pilotage, a vessel with a PEC holder, VTS and subsequently a piloted vessel. As mentioned in my editorial neither the Master of the British vessel involved nor the VTS authority participated in the enquiry and the report has some interesting comments on that policy.

The full report is available from the following link:

www.maib.gov.uk/publications/investigation_reports/2007/arctic_ocean_maritime_lady_sunny_blossom.cfm

Link to the original illustrated magazine article (pdf): http://pilotmag.co.uk/userfiles/Pilotmag%20289%20(Apr%2007).pdf

SYNOPSIS

At 1955 on 5 December 2005, the UK registered 6326gt container feeder vessel, Arctic Ocean, was leaving Brunsbüttel Lock to turn east across the westbound fairway of the Elbe River to head for Hamburg. At the same time, the Gibraltar registered 1857gt general cargo vessel Maritime Lady was in the westbound fairway heading for the North Sea. The two vessels collided at 1957, with the result that Maritime Lady capsized. The master of Arctic Ocean held a Pilotage Exemption certificate and Maritime Lady was below the size where regulation required a pilot to be carried. The MAIB report states that “Both masters were attempting to carry out the duties of pilot and watchkeeping officer. This caused them both to be overloaded at a critical stage of their vessel’s passage, leading to misjudgements”.

The capsized wreck of Maritime Lady drifted until it came to rest in a position 0.75miles south-west of the exit basin of Brunsbüttel Locks.

After the collision, Brunsbüttel Locks were closed until 2100. The first vessel to then leave the locks was the 11598gt chemical tanker, Sunny Blossom. She had a pilot on board and was to head west, to the North Sea, after leaving the lock’s exit basin.

After leaving the lock basin, Sunny Blossom was attempting to make the turn to the west, when her stern struck the wreck of Maritime lady, causing serious propeller damage and a total loss of propulsion. She then continued south across the Elbe River, until she grounded on the south bank. There was only slight damage to her hull and no pollution. Sunny Blossom’s ability to make the westerly turn and clear the wreck of Maritime Lady was hampered by a strong ebb tide, the effects of shallow water, some cropping of her propeller all combined with her effective rudder area being at the lower end of acceptable limits.

The Federal Ministry of Transport, Building and Urban Affairs has therefore been recommended to review requirements for bridge manning levels on vessels in its pilotage waters, emergency procedures, procedures covering the briefing of vessels leaving Brunsbüttel Locks and the prioritisation of VTS operators’ tasks.

Sequence of events.

At 1941 the Arctic Ocean made a routine call to Brunsbuttel Elbe Traffic VTS (BETVTS) providing vessel details and advising them that upon leaving the lock he would be proceeding inwards to Hamburg. It would appear from the narrative that no traffic information was provided to the Master and that no further communication with VTS was held with BETVTS until after the collision!

At about 1950, having let go, the Master who was alone on the bridge, set the engine to half ahead and proceeded out of the lock and commenced swinging to port into the river to cross the Westbound fairway to proceed to Hamburg (see chart). His speed on clearing the lock was estimated at 8 – 10 kts. It was at this stage that the master saw the green navigation light and masthead light of an outward bound vessel which he identified as Maritime Lady from the AIS, and he judged her range as 1.5 miles. This subsequently turned out to be erroneous with the actual range being half that distance at 7.5 cables. Crossing the Westbound lane the Master of the Arctic Ocean noticed that Maritime Lady was still showing a green sidelight. A subsequent VHF exchange between the two vessels confirmed red to red passing but shortly afterwards the Maritime Lady called again on VHF stating that he had steering problems and requested a green to green passing. Both vessels then attempted to take emergency action but the Arctic Ocean collided with the starboard side of Maritime Lady.

Due to the fact that the Master of the Maritime Lady didn’t cooperate with the enquiry the MAIB were unable to obtain an account of his actions. However, examination of the vessel revealed no problems with the rudder or steering gear and it was therefore assumed that the reported steering problems resulted from the Master’s unfamiliarity with using a Becker rudder rather than a mechanical defect. One very relevant point made by the investigators regarding the Maritime Lady is the following important observation on the practice of two man watchkeeping:

Another reason the master was alone on the bridge was that Maritime Lady,

was not required to take a pilot for the river passage. Had a pilot been required, then it is reasonable to suppose that the pilot would have had either the master or the chief officer on the bridge with him. Thus, two qualified navigators would have been on the bridge, offering assurance that neither was overloaded.

The master of any vessel, carrying only a master and one other deck officer, is

likely to be faced with a dilemma in pilotage waters where his vessel is not required to take a pilot. Either the vessel is navigated, often in busy and restricted waters, by just one officer or both officers are on the bridgefor the passage and they risk exceeding the allowable hours of work. Neither is desirable.

BETVTS, having observed the collision, sent out a MAYDAY alert and requested that tugs proceed to the area. The Arctic Ocean broke clear of the Maritime Lady and BETVTS directed her to anchor. An inspection revealed minimal damage.

On board the Maritime Lady the situation rapidly became serious as a starboard list developed as soon as the Arctic Lady drifted clear. Fortunately, all the crew members had lifejackets and launched two liferafts, one of which failed to inflate. The Master contacted BETVTS and requested a location to berth or ground the vessel but the list increased so much that it was decided to abandon the ship. By this time there were two pilot cutters on the scene and all the crew were rescued. The now capsized hull drifted West on the ebb tide to ground just west of the entrance of the lock entrance just South of buoy 58a. The BETVTS closed the river to navigation whilst the situation was assessed and subsequently took the decision to reopen the river to navigation at around 2100. The MAIB report criticises this decision on two grounds. Firstly after only one hour the stability of the grounded wreck could not be realistically assessed and secondly because no risk assessment was undertaken for vessels leaving the lock on the ebb tide despite a history of several vessels having collided with the Buoy 58a close to the North of the wreck!

Sunny Blossom

Sunny Blossom was a 20,000 dwt products tanker 161m long with a draft of 9.3m. bound from Klaipeda to the USA. She had secured in the lock shortly after the collision in the river and her river pilot boarded at around 2040. During the exchange, the pilot sighted the pilot card and at the same time explained the situation regarding the collision and that when they departed the lock that there would be a strong ebb tide setting to the West but with no other shipping movements expected it was agreed that upon leaving the lock that they would alter course to port to clear the wreck to the South. As soon as the river was opened the Sunny Blossom started to leave the lock, clearing the entrance at a speed of about 4.5 kts at 2110. At this point, in anticipation of the tidal effects the pilot ordered the wheel to be put hard to port and the engine order of full ahead was given. Sunny Blossom gained speed but failed to clear the wreck and having damaged her propeller went aground on the south side of the river. She was refloated early the next morning and towed to Elbe Harbour at Brunsbuttel.

During the subsequent dry dock inspection it was noticed that two of the propeller blades had previously been cropped of around 60cm of the tips.

The investigation also discovered that the Sunny Blossom had been involved in two previous groundings and investigations into those had revealed that her rudder was at the lower end of acceptable performance, a restricting factor which would be enhanced with small under keel clearances. The Master did not advise the pilot of either the recognised poor steering characteristic or the cropped propeller blades. The MAIB report has determined that if the propeller blades had been complete then the pilots’ orders would have resulted in the vessel clearing the wreck.

VTS

Since the VTS authority refused to cooperate with the MAIB enquiry its role in the incident cannot be analysed. However in common with the majority of port VTS systems its function appears to be mainly as an information service but with a duty pilot on watch at all times to offer navigational assistance if required by any vessels.

On the evening in question it would appear that the Master of the Arctic Ocean failed to comply with the reporting procedure to notify BETVTS that she was actually departing from the lock. However, since BETVTS failed to advise the Master of the presence of the Maritime Lady proceeding down river at the time of his pre departure report the Master assumed that there was no traffic likely to affect his departure. Although not included in the official procedures for departure the enquiry revealed the existence of a letter issued following a similar collision recommending that VTS provided vessels intending to depart from the lock with relevant traffic movements. Although the VTS refused to cooperate with the MAIB enquiry an internal enquiry, which has not been made public, apparently cleared the VTS operators of any blame and confirmed that correct VTS procedures had been followed.

KEY FINDINGS

Arctic Ocean

The Master of the Arctic Ocean’s made a significant misjudgement in underestimating the distance from the Maritime Lady and since he had no assistance on the bridge the report concluded that the workload was unreasonable and significantly contributed to him misjudging the range of Maritime Lady and since the Mate could have been available considered that he had not properly managed watchkeeper resources.

Maritime Lady

By the stage Maritime Lady was approaching Brunsbüttel, her master’s tiredness might have been sufficient to have resulted in poor judgment and decision making.

Waterway regulations gave Maritime Lady right of way, as she was the vessel in the fairway.

Maritime Lady’s master, with only one other navigating officer on board, did not have the resources to operate with a second navigator on the bridge.

Sunny Blossom

Sunny Blossom’s master did not consider the propeller’s state to be significant and, could not have given the pilot any information on the effect on the vessel’s performance due to the cropped blades.

Sunny Blossom’s sluggish response to her rudder was due to several factors, including: insufficient rudder area and reduced flow over the rudder caused by cropped propeller blades.

VHF

There were fundamental VHF procedural errors made by the masters of Arctic Ocean and Maritime Lady that had the potential to cause confusion.

VTS

Arctic Ocean’s master wasn’t provided with a traffic report when he reported in and therefore assumed that the river was clear. VTS should have informed him of traffic at the time of the initial report.

At the time Brunsbüttel Locks were reopened to traffic, there was no certainty that the wreck of Maritime Lady was not going to move again.

The level of risk to traffic from the wreck of Maritime Lady was not recognised or assessed against predetermined criteria procedures before Brunsbüttel Locks were reopened to traffic. The hazard posed by contact with the wreck was significantly greater than of hitting buoy 58a. It appears, however, that this increased level of risk was not fully recognised or assessed before the locks were re-opened to traffic.

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