Incidents & Investigations
MEESTER PILOT!
Meester pilot where are you? Again!!
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 Read the rest of this entry »
Crimson Mars Investigation
CRIMSON MARS GROUNDING
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 Read the rest of this entry »
MAIB Report: Elbe Collision & Grounding
MAIB Report: Collision on the Elbe off Brunsbuttel Lock.
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. Read the rest of this entry »
Karen Danielson
Karen Danielson
In the April 2005 Pilot I included a report into the fatal collision of the Karen Danielson with the Great Belt Bridge pilotmag.co.uk/userfiles/Pilotmag%20281%20(Apr%2005).pdf. The initial accounts into the disaster questioned why the Danish Belt VTS, which had been installed specifically to monitor traffic in the vicinity of the bridge, had failed to prevent the collision. The full report has now been released and the following account contains the main findings. In my
opinion there is a bit of whitewash over the finding that the VTS could probably not have prevented this disaster since the investigators have seemingly revealed that no operators were monitoring shipping on the relevant display for over 30 minutes. If it is considered unlikely that the operator could have prevented the collision even if he had been keenly monitoring the ship it does rather beg the question why bother with having the VTS and expensively manning it since it is seemingly not fit for purpose?
One common factor amongst all the VTS centres that I have visited is that VTS operators are allocated many administrative duties which inevitably distract the VTS operator from monitoring the displays. If the procedural changes introduced in the Danish Belt centre following the collision were implemented as general VTS policy the increase in manpower required to separately cover the administrative
functions could have a significant impact on cost effectiveness of VTS. The following is edited from the official report.
Link to the original pdf illustrated magazine article (Page 10):
pilotmag.co.uk/userfiles/Pilotmag%20287%20(Oct%2006).pdf
The Karen Danielson was a general cargo ship of 3120 grt, built in 1985 and which collided with the Great Belt West Bridge shortly after leaving the port of Svendborg in Denmark.
1715 The pilot left the ship when it was off Thurø.
1815 The chief officer came to the bridge and shortly after the master left to eat and left the chief officer alone on the bridge.
1820 The course was altered to 005°. The speed was 11.5 knots. It was twilight and the weather was clear.
At approximately 1857 hours the ship was due to alter to an easterly course to pass north of Langeland However, the ship continued on a course of 005°.
1907 Karen Danielson collided with the western section of the Great Belt Bridge and the wheelhouse was torn off.
1912 hours the ship transmitted a Mayday distress signal, and only then did the VTS Centre realise that something was wrong. The master was severely injured in the collision and another crewmember was injured during the rescue. Following salvage of the vessel the chief officer was found dead in the wreckage of the wheelhouse. At the post-mortem examination, the result of the alcohol test proved positive Karen Danielson was equipped with AIS and the ship’s movements from departure from Svendborg and until it collided with the bridge were registered by the Royal Danish Administration of Navigation and
Hydrography
VTS Great Belt
When the decision was taken to build the fixed link across the Great Belt it was also decided to establish a Vessel Traffic Service (VTS) system for safeguarding the link. The Admiral Danish Fleet (SOK) is the operational manager of the VTS-system and the operation is based upon an agreement between SOK and A/S Sund & Bælt Holding, which has economic responsibility.
Extract from VTS Great Belt Procedure:
The task of VTS Great Belt is to supervise the Great Belt traffic to protect the bridges spanning the Great Belt and to alarm in time to stop rail and road traffic in case of a risk of collision with the bridges.
According to the watch schedule the team leader should have taken over from operator 2 at the operator’s desk at 1800 hours. Around that time he was however occupied by a telephone conversation and he also needed to finalize some administrative work and did not take over from operator 2 until approximately 1830 hours when operator 2 informed him about the vessels, which were within the VTS area. The team leader was well aware of the fact that Karen Danielson was too large to pass under the bridge.
After been relieved operator 2 went down to the cellar conduct some tests on new VHF equipment. Between approximately 1840 and 1900 operator 2 called the Team Leader in the operations room three times from the cellar to test the new VHF. At around 1900 hours the team leader was also occupied by printing out the pilot lists from the Great Belt Pilots and checking them against the VTS database. This was the normal watch routine. Operator 1 was then in the nearby pantry dishwashing At about 1909 hours the team leader heard a “Mayday” call. He did not quite understand what was said because the voice calling was exited. The exited voice continued calling “Mayday” and the team leader now understood that the ship was Karen Danielson. The team leader therefore looked at the radar monitor and he could not see the echo of Karen Danielson. He then heard that the person calling say that the vessel was locked under the bridge and he then activated the alarms to the bridge traffic watch, the police and the railway remote control centre.
Alarm – Danger of collision
According to the procedure VTS must immediately inform the police, the railway remote control centre in Roskilde and A/S Great Belt traffic watch when VTS estimate, that the navigation of a vessel towards the West Bridge can create a situation of risk to the West Bridge. If it is estimated that within 10 minutes a vessel will collide with the bridge, VTS activate “alarm”. If VTS estimate that there is a risk that a vessel within 10 to 30 minutes will collide with the bridge, VTS activate “collision warning”.
On 3 March at 1917 hours A/S Great Belt received a phone call from VTS Great Belt.
This was followed immediately after by a phone call from the police in Slagelse. At that time the alarm had not been received. The alarm sounded at 19.17.44 -“collision warning” and “alarm” at the same time. At 1919 hours the police closed the barriers onto the Great Belt West Bridge.
Alarm function on the VTS system
There are several automatic alarm functions in the VTS system. e.g. it is possible to insert a zone on each side of the bridge. Echoes from vessels within the zone will activate the alarm. The automatic alarm function has not been used for the last 8 years.
According to the Admiral Danish Fleet the reason for not using the alarm function is that if used it had to be linked to the 10 minutes warning alarm and that the zone thus would be so great that the alarm would be activated constantly due to ships which were not a risk to the bridge.
The team leader on duty at the operator’s desk at the time of the collision, has told the investigators that he had concerns in relation to his work and thinks this, the administrative work with pilot lists and the radio check have been essential contributory factors to his failing concentration and the fact that he did not notice that the echo of Karen Danielson continued on an unchanged course towards the bridge.
The team leader is also of the opinion that the colours on the radar screen are not suitable. The head of VTS Great Belt has told the investigators, that it is possible to use screen adjustments decided by the user. He also advised that the screen adjustments have been discussed at meetings at the VTS Centre. Because it is fast and easy to adjust the screen, they had agreed that each operator should choose the adjustments he or she preferred.
Analyses
The chief officer, who was killed in the collision, did not initiate a turn to the east
at waypoint 107, in accordance with the passage plan despite the fact that the GPS
Navigator had been sounding on the bridge from the time the ship passed
waypoint 107 at 1857 hours and until the collision at 1907 hours. The available
evidence therefore suggests that the chief officer had fallen asleep, some time after
the alternation of course which he made at 1820 hours to 005°.
VTS Great Belt
The VTS Great Belt procedures did not include rules on the watch team’s internal
organisation. The watch had been organised according to regular practise. In the period prior to the collision, only a few ships were in the VTS area. It was not until 10 minutes prior to the collision that something out of the ordinary happened. The fact that the surveillance of the VTS area had been left with only one operator contributed greatly to Karen Danielson’s steady course going unobserved and it also prevented the VTS-centre from trying to contact Karen Danielson and warn that the vessel was standing into danger. According to the Admiral Danish Fleet, the internal watch procedure has been
changed to the effect that there are now always two operators in the immediate vicinity with the operator’s desk. One of them is primarily responsible for communication and the other one is primarily responsible for watching the radar screens.
Plotting
At no time was the VTS-centre in doubt as to the identity of Karen Danielson. The
pilot’ report had been received, there were no other echoes on the screen that could be
confused with that of Karen Danielson, and the AIS information was also available. Therefore, the VTS-centre did not request Karen Danielson to report in at a given point within the radar coverage and the centre did not call the ship after the ship had appeared on the radar screen. Irrespective of the fact that the VTS-centre had no doubt about Karen Danielson’s identity on the radar screen, the investigators were of the opinion that, that
by omitting to request the ship to report and by omitting to call the ship, the centre
cut off themselves from direct contact with Karen Danielson’s master or the officer on
watch and hereby the positive effect such contact could have had to get the attention
of the person on watch. The investigators were of the opinion that the lack of proximity alarms prevented the inattentive operator on duty from being warned about the danger of
collision with the bridge.
The possibility for the VTS-centre to prevent the collision In order to prevent the collision, the VTS-centre should have followed Karen Danielson on the radar and realised that the ship was not turning as expected. If the VTS-centre had followed Karen
Danielson on the radar, the centre would only have had reason to assume that
something was wrong approximately 9 minutes before the collision occurred
because the ship did not turn east. The VTS-centre could have called Karen
Danielson on the VHF or sent out the guard vessel from Slipshavn.
The chief officer on Karen Danielson was alone on the bridge. It is not possible
to determine whether he would have heard a call on the VHF. He did not hear the
“line alarm” from the GPS navigation which sounded for about 10 minutes.
It would have taken approximately 10 minutes from the VTS-centre’s alarm for
the guard vessel to get close to Karen Danielson. This would have been too late
in this case. Even if the VTS operator had realised that Karen Danielson was not
turning east, it is doubtful whether it would have made any difference to the
collision. The Admiral Danish Fleet has stated that they have established the following special procedures for ships that are navigating from Svendborg into the VTS area:
· Svendborg Port informs VTS Great Belt by fax when a ship departs
· The VTS-centre calls the ships 5-10 minutes before they reach the turning point and asks them to confirm their intention to alter course.
The full report can be downloaded from:
www.soefartsstyrelsen.dk/sw8455.asp
Footnote: The hours culture applicable to seafarers!
Although no new crew members were involved in the incident the investigators noted a disturbing factor around how crew changes are now undertaken in total contravention of the Working Time Directive which results in ships’ personnel joining the vessel in an already extremely fatigued state. The report notes:
The 2nd officer together with four other new crew members joined the vessel around 1000 hours on 3 March 2005 after travelling by mini-bus from Split in Croatia to Svendborg, in Denmark. This was a direct drive of 26 hours, they were accompanied by two drivers and a crew manager from the manning agency. Upon arrival at the ship they went through their respective handovers and the departing crew members left to return to Croatia with the same mini-bus shortly after 1400 hours on 3 March. The joining crew went straight on duty upon arrival at the vessel.
Due to the busy work schedule planned for the 3rd March, all on board, both existing and newly joined crew worked throughout the day on the 3 March 2005.
I understand that this appalling disregard of the “Human Element” is apparently now common practice as a means of saving the cost of hotel bills and air fares.
JCB
Cape Flattery & APL Panama
MEESTER PILOT WHERE ARE YOU?
All pilots know that the pilot boarding and landing area is one fraught with hazards, not least because whilst awaiting their pilots many vessels’ masters appear to forget about navigation and seamanship, either in their desire to be first in the queue or because once they see the pilot cutter they relax their guard. Collisions and near misses are regrettably not infrequent. IMO resolution A960 and the boarding and landing code detail the need for such areas to be placed where there is adequate sea room to manoeuvre but there have recently been two serious groundings as a result of Masters failing to wait a safe distance off the port and proceeding past the charted pilot boarding area into disaster. These groundings involving the vessels Cape Flattery and APL Panama, occurred despite there being no other vessels navigating in the vicinity to restrict their ability to manoeuvre and both highlight how poor navigation, coupled with a loss of vigilance by the bridge team, can, in a few moments result in claims running into tens of millions.
Whilst the report into the Cape Flattery has recently been released, the report into the grounding of the APL Panama off Ensenada has not yet been concluded but there is sufficient evidence to point to a total failure of the bridge team during the approach to the port.
Link to the original illustrated pdf article (Page 7):
pilotmag.co.uk/userfiles/Pilotmag%20286%20(Jul%2006).pdf
M.V. Cape Flattery:
Barbers Point Harbour. Oahu, Hawaii.
The 170m long bulk cargo ship Cape Flattery loaded with around 27,000 tonnes of cement went aground on a coral reef about 4 cables from the harbour entrance on the morning of February 2, 2005. The ship remained aground for nine days until enough cargo was removed to refloat it and the damage to the ship is estimated at around $21 million. Fortunately no one was injured and there was no pollution but the reef was badly damaged and the restoration costs of this will be considerable. The Coast Guard investigation of the incident concluded that the grounding was caused by negligence by the captain and he was condemned for:
· Not waiting for the Honolulu-based pilot to board prior to entering port as required by port rules.
· Failing to respond to the pilot’s radioed advice that the vessel was standing into danger and that he should alter course. _ Not using radar, not paying heed to channel lights and markers, and not following the charted course for the harbour entrance. The investigation also faulted the ship for not having a functioning echo depth-sounder and not having enough ship’s officers on the bridge.
In his defence the Chinese Captain told Coast Guard interviewers that he had expected Aloha Tower to inform him if he needed to wait for the pilot and the report also states that he also was angry that neither the Coast Guard or Aloha Tower had warned him that he was in dangerous waters!!
APL Panama: Ensenada, Mexico.
Although the official report into this grounding will not be released for some time there is a wealth of comment on this disaster on the Internet mainly because the vessel found its way onto a popular tourist beach on Christmas day where during the next 80 days it provided an interesting spectator event as containers were offloaded by helicopter, a temporary roadway and quay was constructed and an increasing number of tugs arrived to try to salve the vessel. The vessel was finally towed clear on 10th March following the construction of a special dredged channel!
In an almost identical set of circumstances to the Cape Flatterygrounding the vessel failed to stop and wait near the pilot boarding position. It is alleged that although the pilot was booked for 1900 the Master had advised his agent that he would be at the pilot boarding position at 1800 and was annoyed that the pilot was not there to meet him. There are several press reports which indicate confusion and failure of the bridge team, but whatever actually happened on the bridge the result was that the APL Panama ended well up the beach indicating a high speed grounding. The pilot was on his way out to the vessel and saw the impending disaster unfolding. The following is an extract from
The San Diego Union-Tribune. “Capt. Fernando Ramirez Martinez (the allocated pilot) said he and a co-pilot were leaving the port to meet the vessel about 6pm Dec. 25 when they spotted the 880-foot vessel heading across the harbour’s entrance channel and aiming straight for the shore. “I saw the lights and I couldn’t believe it, I just couldn’t believe it. I told the tugboats, ‘Leave the port, because the ship is about to run aground. I suggested to him that we get the tugboat Coral and send it a line so that it could try to keep (M/V APL Panama) at that position. The captain said he didn’t want to give the line, that he couldn’t because that would mean it was salvage and would prompt a host of legal problems”. The report goes on to state that half an hour passed before the Captain agreed to pass a line to the tug but by then it was too late. The Newspaper also consulted experts on the possible claims that would be made which they listed as follows:
Delay expense, salvage operators, equipment rental, lost cargo bookings, lost revenue, security, vessel rotation disruption, cargo claims, environmental claims, lawsuits, legal expense, environmental clean up expense, increased insurance premiums, fines, penalties, lost manufacturing time, product delivery delays, bribes and crane expense for pizza delivery up to the crew. (They are probably still liable for the pilotage charge as well!! Ed.)
Despite these two dramatic cases there are still those who feebly argue that compulsory pilotage is a waste of money and restricts free trade!!
An on-line weblog with some excellent photos cataloguing the whole saga can be found at:
www.cargolaw.com/2006nightmare_apl_panama2.html
Loads of other interesting links there as well.
Stolt Aspiration / Thorngarth
MT STOLT ASPIRATION / TUG THORNGARTH
MAIB REPORT
A consequence of changes to traditional tug operations has introduced new challenges for both tug masters and pilots. The increasing popularity of Azimuth Stern Drive (ASD) tugs has introduced a particular handling change since most of these tugs are designed with a bow towing winch resulting in towage over the bow. When on the stern or operating in the push/pull mode this does not cause too many problems but if required to operate on a centre lead the operation has increased risks of which pilots should be fully aware. On page 13 there is a review of the a monograph on this mode of towage published by the Nautical Institute and I would recommend that all pilots operating with tugs in this mode read this book in order to be aware of the risks and if possible also hold liaison meetings with the tug masters. When things go wrong operating in this mode the tug can rapidly lose control and the following is an edited extract from an MAIB report into one such incident.
Link to the original illustrated articlae (page 10):
pilotmag.co.uk/userfiles/Pilotmag%20285%20(Apr%2006).pdf
Stolt Aspiration, a 7901gt chemical tanker was bound for East Lewis Quay, Birkenhead. Entrance to the Birkenhead Docks is through the Alfred Lock The master and pilot had discussed the passage plan, and the pilot had signed the ship’s information sheet. Thorngarth, a Twin Azimuth Stern Drive (TASD) tug of 45t bollard pull, had been tasked with assisting Stolt Aspiration along with the tug Ashgarth. Both Thorngarth and Ashgarth were TASD tugs and towed over the bow. The two tug masters agreed that Thorngarth would act as the bow tug during the planned operation. Neither tug had any mechanical defects. As Stolt Aspiration approached Alfred Lock, the pilot began reducing speed steadily from 10 knots. The master of Thorngarth requested that Stolt Aspiration proceed at slow speed to allow the connection of the forward towline and, as this was normal practice, the pilot agreed. As the tugs approached, the pilot noted his speed through the water as 6.5 knots and slowing. Ashgarth reported that his line was being made fast and that he was happy with the speed. Thorngarth then began to make his approach. Because Thorngarth is designed to pass its towline from its bow, the tug had to approach Stolt Aspiration bow-to-bow, then manoeuvre stern-first to maintain the correct station off the larger vessel. The pilot was unhappy with the speed of Thorngarth’s approach, and warned the tug master. The tug slowed and the approach continued. Thereafter, Stolt Aspiration maintained a steady course, with the speed continuing to slowly reduce. Having received a heaving line from Stolt Aspiration, and having positioned close under the ship’s bow, Thorngarth backed away from her. The tug’s stern began to move to port, and this was corrected to maintain its position right ahead of the ship. However, the tug’s stern began to move to port again, which caused Thorngarth to move quickly across to the starboard side of Stolt Aspiration’s bow which, at this stage, was approximately 6 metres away from the tug. The tug master again attempted to position Thorngarth directly ahead of Stolt Aspiration’s bow, but this time, the corrective action caused the tug to move directly into the path of the vessel’s bulbous bow. Stolt Aspiration struck Thorngarth on its starboard side, causing the tug to heel heavily to port while being bodily displaced to port by the impact. On Stolt Aspiration, the pilot, noting the movement of Thorngarth’s masthead light, immediately ordered full astern, and used the bow thruster to counter the transverse thrust of the propellers and to maintain the vessel’s heading. Ashgarth also began to pull directly astern at full power to slow the ship. Thorngarth managed to pull clear and since she could no longer assist the ship was released and the Stolt Aspiration resumed the berthing operation without further incident.
Findings
The master of the Thorngarth had been appointed to the tug 10 days before the accident and had never carried out this manoeuvre on this tug and, although as mate he had seen it done on tugs of similar configuration, he was not fully familiar with the manoeuvring characteristics of Thorngarth. The collision occurred when the tug
master was re-positioning his tug ahead of the ship In backing away from the ship’s bow, the stern of the tug began to move to port. To correct this, he pushed the port ahead-astern handle forward, which swung the stern back to starboard. However, this slowed the tug and it closed the ship. Engine speed was increased to regain position ahead of
the ship. Once ahead of the ship, the stern again moved to port and again the port ahead/astern control handle was pushed forward to correct the swing. Because Thorngarth was now to starboard of Stolt Aspiration’s bow, as speed reduced due to
the change in astern power, she ended up on the starboard bow of Stolt Aspiration.
In attempting to recover from this position, the tug master caused Thorngarth to move across the closing bow of Stolt Aspiration where he was hit on the starboard side.
Tug manoeuvring controls and their propulsion systems cover a wide spectrum and, even among tugs of the same type, the speed of reaction of the propulsion gear to a control input will vary. As a consequence, any tug master will need to spend time familiarising himself with the controls of a new tug, even if he is familiar with the propulsion type and control system. Although the change of personnel between different types of tug is a necessary part of the flexible operation of a tug fleet, doing so without extensive initial or ongoing familiarisation training, where the complexities and nuances of control of different tug types can be properly understood and practised by the personnel concerned, will inevitably increase the risk of mistakes being made during operational situations. It was assumed that by the time an individual qualified as master, he would have experienced every type of tug manoeuvre, and that this experience would have been overseen by at least one other experienced master. No records were kept to monitor the training and experience gained.
OTHER INCIDENTS
Two similar accidents occurred elsewhere within the UK, within 4 months of the
collision between Thorngarth and Stolt Aspiration. In the first, a tug was operating
as the stern tug in moving a ship astern. After being asked to pull the ship’s stern to
one side, the tug found it could not regain its original position, and collided with the
ship’s stern. The second incident occurred when a tug, acting as the bow tug in a
berthing operation, was manoeuvring to pass its towline to the ship. Once the line
had been passed to the ship, the tug intended to move ahead of the ship, but collided with her bulbous bow. In neither case were there any injuries or pollution caused. In both cases, the tug masters had a wealth of experience in tug operations within their respective ports. However, both were operating tugs with unfamiliar propulsion systems and manoeuvring controls, and attempting manoeuvres with
which they were not entirely familiar. Safety issues identified as a result of the investigation.
1. Fatigue was not an issue in this accident.
2. There were no mechanical failures on either vessel that could have led to the collision.
3. The accident occurred when the tug master of Thorngarth was adjusting his position ahead of the ship and, due to his unfamiliarity with the tug, misjudged the amount of control movement required.
4. There was little that Stolt Aspiration’s crew could have done to prevent the collision.
5. Although the change of personnel from tug type to tug type is a necessary part of the flexible operation of a tug fleet, doing so without extensive initial or ongoing familiarisation training, where the complexities and nuances of control of different tug types can be properly understood and practised by the personnel concerned, will
inevitably increase the risk of mistakes being made during operational situations.
6. The bow-to-bow approach is conducted many times a day by tugs throughout the world.
7. No formal guidance was given to pilots concerning the capabilities and limitations of tugs in the port.
8. The introduction of new qualifications for Inshore Tug Operators has standardised the training requirements. The previous system was not satisfactory in that it relied on
personnel gaining the relevant experience over time but no records of experience gained were maintained.
9. The pilot and master of a ship would not know which type of tug has been allocated to the vessel until just before the planned operation. However, they could be confident that the tug would make the bollard pull requirement and would be capable of carrying out the designated task, despite not necessarily being the optimum choice of tug for the task.
10.There was no forum for the tug operators, pilots and port authority to raise matters of mutual concern.
11.By not informing the VTS operators of the accident, the VTS operators were unable to co-ordinate the response from the rescue services.
12.Two other accidents occurred elsewhere in the UK in a short period of time, both also caused when tug masters were operating tugs with unfamiliar propulsion systems and
manoeuvring controls, and attempting manoeuvres with which they were not entirely familiar.
RECOMMENDATIONS
The British Tug Owners Association is recommended to:
Encourage its members to ensure that the movement of personnel between tugs is
closely monitored, and that training and expertise of tugs’ crews are matched, and
are consistent with the type of tug and its expected task requirement.
Major Tug Operators, the British Tug Owners Association, and the PMSC Steering Group are jointly recommended to encourage regular formal discussion between port authorities, pilots and tug operators. All parties should be involved in the decision-making process, which will decide the optimum allocation of tugs for all manoeuvres within a port, and the level of crew experience required for each task.
Pilot Error
PILOT ERROR?
Once again pilots are being targeted as ship wreckers by influential London P&I club and the following report by Janet Porter (Lloyd’s List Friday July 15 2005) makes for somewhat depressing reading.
LIABILITY insurers are starting to collate data on pilot error after a noticeable rise in the number of maritime accidents that are not the fault of the shipowner. Leading the initiative is the London P&I Club, which has become alarmed at the level of claims
arising from accidents when a ship was under pilotage. Having made great strides in improving maritime safety through initiatives such as the International Safety Management Code, the shipowners’ mutual is now urging regulators to turn their attention to pilots. “We’ve smartened up our act, now the time has come to look at others, and that includes pilots,” said Paul Hinton, chief executive of A Bilbrough & Co which manages the club. The problem is highlighted in the club’s annual report published today, which draws attention to the fact that many accidents occur either during pilotage, or shortly before of after picking up or dropping off a pilot. “This is an area currently being investigated by managers with the aim of providing advice to masters and supplementing bridge procedures,” the report states. The International Group of P&I Clubs is also gathering information about the number and value of claims that involve pilots. Writing in the annual report, Mr Hinton notes that collisions again featured prominently during the 2004/5 year, “despite universal adoption of the ISM Code, advanced navigational equipment, and passive vessel traffic management systems, and a disproportionate number gave rise to examination of the conduct of pilots who were on board at the time.” With the number of cases involving shipowner responsibility falling, and the trend towards accidents resulting from mistakes of thers increasing, the London Club suggests that governments “need now consider extending more widely, or redirecting the cutting edge of, their regulatory activity.” The club points out that shipowner responsibility is usually difficult to avoid, even when the vessel is under the command of a pilot, since pilots are generally protected by statute from liability, “even when, as is usual, they were effectively in control of navigation.”
In my opinion part of this report reveals a certain ignorance of pilots and pilotage but perhaps the enthusiasm with which the London P&I club are seeking “look at others and that includes pilots” may not be such a bad thing. As the UKMPA has learnt, it is frequently the case that the P&I clubs automatically classify any incident that happens in pilotage waters as “pilot error” even though the Master may have had some involvement in the events leading to the incident. As was revealed at the Master/Pilot relationship Seminar in Bristol last year, the P&I Clubs don’t analyse the incidents closely because they pick up the bill regardless of who was actually responsible. The other glaring fact is that ports and their approaches represent the highest risk areas on a vessels voyage and with pressures to cut costs such as tugs, boatmen etc and with ships ever bigger and more difficult to handle it is hardly surprising that port claims are not reducing. Another factor is that the costs involved in repairing damage to a jetty or vessel have escalated way beyond inflation in the last few years. It could well be that closer investigation could reveal that the number of claims has actually reduced but the increased costs of claims have distorted the statistics. We should perhaps welcome this spotlight being placed on pilotage and at least part of the industry is not so condemnatory. One leading insurer is quoted in response as stating “It would be a classic statistical misinterpretation to conclude from the fact that many ship accidents occur when the pilot is on board, that going without a pilot would improve safety.” Geoff Taylor has already established contact with a P&I Club insider and we should perhaps consider getting some of these insurers along on some pilotage passages.
JCB
Stolt Tern Grounding
STOLT TERN
I have decided to make the MAIB report into the grounding of the Stolt Tern the feature subject this quarter because the report covers many of the issues currently high on the UKMPA agenda. The grounding occurred in daylight and near perfect conditions and the pilotage was undertaken by an experienced pilot who had piloted this vessel and her sister ships many times to the same berth. The incident thus confirms that no matter how many times a pilot has undertaken a particular passage, pilotage is never
Link to the original pdf illustrated article:
pilotmag.co.uk/userfiles/Pilotmag%20283%20(Oct%2005).pdf
“routine” and pilots have to be permanently vigilant and be prepared for the unexpected. Only high quality training can help to prepare a pilot to cope with the unexpected.
The pilot and master both exchanged information in accordance with current “best practice” but the pilot’s passage plan is criticised in the report for not being sufficiently detailed in providing clearances from the breakwater and tracks to the
berth. I must admit that I disagree with this criticism because one of the primary roles
of a pilot is to be able to have flexibility during a passage rather than running on fixed tracks and if he has been trained professionally his detailed knowledge of the district permits him to know where the ship can and cannot be positioned depending on the vessel’s draft with respect to the height of tide. Pilots have to deviate from the “track” to facilitate overtaking or collision avoidance and in my experience the presence of a fixed track on a passage plan can cause more problems than it can potentially resolve in that deviation from a rigid track will cause the OOW to be constantly questioning the pilot and introduce doubt, confusion and distraction within the “bridge team”. Those who pilot warships will be only too aware of this! I feel that “best practice” would be that if the pilot is to depart from a “normal” track then he should inform the master of the reason and provide details of the height of tide in relation to the draft and provide the minimum UKC to be anticipated during the deviation. In this way the “bridge team” (as much as it exists in reality!) will be reassured and the OOW can, if he wishes, double check the calculations. Many vessels now shade-in shallow areas on the chart where the vessel should not navigate and this is considered good practice by
inspectors. Unfortunately, such shading is usually based on chart datum and takes no account of tidal height. For many tidal restricted vessels the whole piloted passage
can be undertaken through these shaded “no go” areas! Practically, it would be impossible to produce a passage plan shading in the actual no go areas unless the
vessel was fitted with an advanced ECDIS incorporating “real time” tidal data corrected for any tidal surges or cuts in tidal level. To the best of my knowledge such real time tide (and in Australia swell) corrected ECDIS is limited to a few specialist, port specific portable pilotage laptop units. Once things start to go wrong the Master pilot relationship is critical and unless both the Master and the pilot realise that the plan is unravelling and, more importantly, are in agreement as to how the situation can best be resolved then an incident is almost inevitable. One common factor in all pilotage related incidents is the rapidity with which a routine passage or manoeuvre transforms into a disaster. In this case it appears that the approach went from normal into a grounding scenario within 2-3 minutes. The reason on this occasion appears to be that the Master over ruled the pilot by reducing speed to less than that ordered by the pilot and used the bow thruster without being instructed. I believe that in this case, even if a “safe” track had been placed on the chart, the grounding would still have occurred
because the master (being unfamiliar with the port) was obviously concerned that the
vessel was going too fast and not swinging to starboard fast enough and thus reduced
the pitch more than requested and then whacked the thruster to starboard. His actions were therefore entirely successful in achieving what he thought was required rather than what the pilot had requested!! This incident happened whilst the vessel was under pilotage and therefore the grounding will automatically be put down to “pilot error” by the insurers! (see p.14). The report highlights the need for pilots to be fully trained and recommends that ports fully support pilots by providing on-going professional development. Further to this, the report acknowledges the importance of pilots being subjected to National Occupational Standards. This is what the UKMPA have been trying to implement since the NOS document was produced in 2001 and hopefully the
recommendations of the MAIB will accelerate the conclusion of this work. Finally the MAIB measures Holyhead port’s compliance with the requirements of the Port Marine Safety Code and also for the first time refers to the “best practice” detailed in IMO resolution A960. This report therefore reinforces the arguments made by the UKMPA of the need to draw up a new Pilotage Act to incorporate the PMSC and pilots’ NOS.
The following is an edited version of the full MAIB report.
REPORT
At 0915 on 1 December 2004, Stolt Tern approached the pilot embarkation position off Holyhead with a cargo of 4000t of gas oil. On arrival on the bridge, information was exchanged between the master and the pilot. The pilot was given the ship’s pilot information card and supplementary information regarding her Becker rudder that reductions in speed should be made gradually and not when changing heading. The pilot gave the Master the port passage plan to the intended berth. The pilot advised the master to alter course to put the breakwater fine on the starboard bow and manual steering was selected.
The master controlled the pitch control lever, and the third officer was on the helm, except when relieved by the master to allow him to plot fixes on the paper chart.
The speed was reduced to slow ahead when about 5 cables from the breakwater. Soon after, the pilot advised a 10° alteration to starboard to aim towards a prominent chimney. The third officer applied 5° of starboard helm. The master also gave a short burst of the bow thruster to starboard, and reduced to dead slow ahead, in accordance with advice he thought the pilot had given.
The ship started to swing quickly to starboard. The pilot commented that the stern was being influenced by the tidal stream and ordered ‘midships’ followed by ‘steady’. As the third officer applied 20° of port helm, the pilot advised ‘hard to port’. Although 35° of port helm was applied, and the bow thruster was thrust to port, the ship continued to swing quickly to starboard.
Realising that the ship was swinging towards the breakwater, the pilot advised the master to ‘stop’ followed by ‘full astern’. The third officer responded by stating in Filipino that this action would accelerate the swing towards the breakwater end. Accordingly, the master increased to half ahead and increased the port helm to 65°. Moments later, at 0940, the ship grounded on a patch of shoal water to the south of the eastern end of the breakwater. Estimates of the speed of grounding range from 2 to 6 knots.
ACTION TAKEN FOLLOWING THE COLLISION AND DAMAGE
The vessel was re-floated with the assistance of the tug Afon Braint at 1120, and was secured alongside Terminal 4 at 1215. There was no pollution.
Following a temporary repair, the vessel sailed to Rotterdam for permanent repairs.
ENVIRONMENTAL CONDITIONS
The wind was south-east force 1-2, and the sea was calm. The predicted mean rate of the tidal stream in the position of tidal diamond ‘B’ was 102° at 0.5 knot.
RECORDED INFORMATION
The course recorder was found to be reading 10 minutes slow, and 10° low. The ship was fitted with a propeller pitch recorder, but this was not working. The port’s radar was operating but did not have a recording capability.
NAVIGATIONAL PUBLICATIONS AND PASSAGE PLANS
The chart in use for entry into the port was BA 2011, the largest scale chart available and generally corrected up to date The port passage plan did not show the intended routes to the port’s berths.
THE PILOT
The pilot was 65 years old and was raised in Holyhead. He had served on board deep-sea ships, and had been qualified as a master since 1966. From 1970, he worked onboard ferries operating out of Holyhead, where he held a PEC. He was promoted to Master in 1980 and served continuously in that role until 1993. After ceasing to be a ferry master, he remained employed in the port overseeing dredging operations, and as a standby pilot. He became the port’s principal pilot in 1999. He conducted between 150 and 200 pilotage acts each year. The pilot had not experienced any accidents or near accidents during his time in Holyhead, and the Port Authority had not received any adverse comments from third parties regarding his performance. He was well respected for his knowledge and shiphandling ability by the port’s senior management, and maintained a keen interest in the operations of the port and in 2002 had also suggested that a permanent navigation mark be placed to mark the shoal water to the south of the breakwater end. In addition to his pilotage duties, the pilot had also voluntarily assisted the harbourmaster in the oral examination of over one hundred PEC candidates. He was well rested when he arrived on board Stolt Tern.
Intentions
The pilot expected the ship to be set to the east by the tidal stream as she proceeded towards the harbour entrance. He estimated that the rate would be a maximum of between 2 and 3 knots, and anticipated this would cause the ship to pass between 1.5 and 2 cables off the breakwater end. The pilot was aware the ship might experience a turning moment to starboard when for a brief period, the stern would continue to be influenced by the tidal stream, whereas the bow would not, and had identified a need to ensure that the ship was on a steady course during this period.
Recollections
The pilot stated that he never advised ‘dead slow ahead’, or for the bow thruster to be used when initially altering course to starboard. After port helm was applied to steady the ship, the pilot remembers the ship being steady on course for about 2 minutes, and that it was not until the breakwater head was on the starboard beam, at a distance of between 1.5 and 2 cables - that the sheer to starboard developed. From where the pilot was standing, he could not see the CPP control lever, or ship speed indications, but could see rudder angle and propeller pitch repeaters. He was conscious of the master making adjustments to controls on the console.
PILOTS AND NAVIGATION SAFETY
When the pilot was retained as the port’s principal pilot in 1999, there was no formal process for the authorisation of pilots in place. His PEC was transferred to a pilot authorisation without an examination being conducted. During the pilot’s time in post no formal checks had been made on his performance. The pilot was not employed on board ships over 10000grt using the Aluminium jetty. Mersey pilots were employed on these ships because of their need for tug assistance, The port’s pilotage committee was chaired by the harbourmaster and comprised the port’s major users, including the pilot, and other interested bodies. The committee’s agenda typically included all aspects of the safety of navigation, and pilotage within the port.
PORT MARINE SAFETY CODE
The PMSC was developed by the Department for Transport and was implemented in December 2001. The code introduced the principle of a national standard for every aspect of port marine safety, and although the code was not mandatory, the Department for Transport expected every CHA to comply with its requirements. These included the completion of formal risk assessments of marine operations.
National Occupational Standards
In its review of the PMSC, published in November 2004, the
Department for Transport concluded that:
MCA should continue to engage with the industry on occupational standards until it is generally established that these underpin the recruitment and statutory authorisation of those key positions - this needs to include the promotion of formal training in assessment.
National occupational standards for pilots have been agreed and accredited with the QCA. However, the assessment criteria for their implementation have yet to be agreed.
IMO RESOLUTION A.960 - PILOT TRAINING
Resolution A.960(xxiii) contains recommendations on the training and authorisation of pilots, and recommends that harbour authorities should satisfy themselves that pilots continue to possess up to date knowledge (at intervals not exceeding 5 years) of local navigational issues, current regulations and any other specifically related local issues. It also states:
Every pilot should be trained in bridge resource management with an emphasis on the exchange of information that is essential to a safe transit. This training should include a requirement for the pilot to assess particular situations and to conduct an exchange of information with the master and/or officer in charge of the navigational watch. Maintaining an effective working relationship between the pilot and the bridge team in both routine and emergency conditions should be covered in training. Emergency conditions should include loss of steering, loss of propulsion, and failures of radar, vital systems and automation, in a narrow channel or fairway.
The harbourmaster of Holyhead was unaware of the content of Resolution A.960(xxiii).
LOSS OF CONTROL AND GROUNDING
After the pilot embarked in Stolt Tern, the initial passage towards the breakwater proceeded as planned. However, as a small alteration of course to starboard was made to the north of the breakwater, the turn could not be checked and the ship started to turn from a course of 139° at 0937, and grounded at 0940 on a heading of 232°. It is estimated that the ship’s mean ground speed during this period was between 3 and 4 knots. In the absence of any indication of a machinery malfunction or failure, the loss of control was probably due to one, or a combination, of several factors.
First, the time interval between the engine movements from half ahead to dead slow was short, and the resulting reduction in speed would have been quite rapid. Given that the ship was known to be extremely right-handed and that the pilot information card warned against reducing speed and changing heading at the same time, a sheer to starboard was a likely outcome.
Second, as Stolt Tern passed the end of the breakwater, her bow would have entered the still waters to the south, while her stern would have been set to the east by the tidal stream to the north of the breakwater. This would have exacerbated the ship’s turning moment, and her slow speed would have prolonged her exposure to this effect. Third, although the time the bow thruster was used at the start of the turn was stated by the master to have lasted only a few seconds, its use is likely to have had an influence given the ship’s slow speed. In conjunction with the 5° of starboard rudder, which according to the information in the pilot card equated to about 15° of conventional rudder, this could have induced a high rate of turn unless quickly checked.
It is impossible to determine if the grounding would have been avoided had the master followed the advice of the pilot and put the engines astern. The master’s decision to ignore this advice, and to increase speed and rudder, was based on his knowledge and experience of the ship’s manoeuvring characteristics. It is correctly the prerogative of the master to take such action, whenever he considers appropriate.
BRIDGE MANAGEMENT AND COMMUNICATION
Before entering Holyhead, relevant information had been passed between the pilot and the master.
However during the execution of the passage plan the pilot was not integrated into the bridge team. The master’s rapid reduction of speed, and his use of the bow thruster, resulted from poor communication between the master and the pilot. The pilot was not aware of the action taken because the master did not inform him. He was concentrating on conning the ship and did not monitor the master’s actions.
The pilot estimated the ship’s position and movement by eye. He did not ask for any of the additional information available to the bridge team, such as ranges by radar or speed over the ground, nor was any of this information offered.
The pilot was isolated from the decision-making process during the discussions between the master and third officer, in Filipino, immediately before the grounding. The integration of pilots into a bridge team is essential if passages in pilotage waters are to be conducted safely. On this occasion, it is not certain why the master reduced speed to dead slow. He was operating the CPP controls, and was aware of the ship’s handling characteristics. However, better teamwork and a more effective working relationship between the master and third officer, and the pilot, might have helped to recognise what was going wrong with the plan in sufficient time for corrective action to be taken.
It is understood that some of the larger ports arrange for their pilots to attend tailored bridge simulator courses as part of their ongoing professional development. Such training would probably be of benefit to all pilots.
PASSAGE PLANNING
The intended passing distance off the breakwater allowed insufficient sea room and time for corrective action to be taken. A similar accident could easily have occurred had the ship suffered a mechanical failure.
There was no reason why a greater clearance could not have been planned. However, the pilot had followed the intended route and passed the breakwater many times without incident, and it had become custom and practice.
Although the bridge team had produced a pilotage plan for entry into the port, the lack of tide tables indicates that the master was reliant on the services of the pilot for this information.
PORT SAFETY MANAGEMENT
In keeping with the Port Marine Safety Code, the port of Holyhead was operated under a safety management system. Assessments had been made of all identified risks related to marine activities, and these had been periodically reviewed.
The simple and cost free precaution of allowing a larger safety margin when passing the breakwater end was not identified. This was particularly relevant to the ships on passage from the pilot station to Terminal 4, which needed to make a large turn around the breakwater end. The precaution was probably not identified due to the fact that the entry to the port is relatively straightforward, there was no experience of previous accidents in this area, and the port’s management, which was very experienced in ship and port operations in Holyhead, was highly respectful of the pilot’s ability and experience. Risk assessment is a very useful tool to quantify and reduce risk through the identification and implementation of suitable control measures. However, unless the control measures themselves are regularly reviewed to ensure that the risks are being kept as low as reasonably practical, the effectiveness of the risk assessment process is diluted. Liaison with the persons providing the control measures is essential to achieve this.
PILOT AUTHORISATION AND PERFORMANCE MONITORING
Since the pilot had been in post, the port had improved and formalised its procedures for the authorisation of pilots. This was demonstrated by the authorisation procedure followed for the standby pilot, and the pilots employed from the Mersey. The requirements for PECs were also clearly defined. The authorisation of the pilot on board Stolt Tern pre-dated these procedures, and he had never undergone any formal assessment in his role. However, the harbourmaster had monitored the pilot’s performance by accompanying him on the occasional act of pilotage, and by witnessing his shiphandling from ashore.
Local navigational knowledge and shiphandling are obviously pivotal to a pilot’s performance but there are other areas in which a pilot must also be proficient. It is difficult for harbour authorities to effectively monitor performance in all aspects of a pilot’s work, but a requirement for all pilots to have a qualification based on national occupational standards would at least provide a reliable base from which to start.
ONBOARD PROCEDURES AND SAFETY MANAGEMENT
A number of departures from the company’s procedures and material deficiencies, with respect to navigation and bridge management, were evident on board Stolt Tern. These included: the lack of tide tables; the chart in use not being corrected up to date; the lack of a helmsman on the bridge; the lack of a bridge team brief prior to entering the port; the lack of assistance provided to the pilot in terms of his familiarisation with the bridge equipment and general support; the interchanging of the master and third officer on the helm; the use of Filipino rather than English just before the grounding; the misalignment of the course recorder; and the non-functioning of the propeller pitch recorder.
RECOMMENDATIONS
The BPA/UKMPG marine and pilotage group is recommended
to:
Highlight to members of the BPA and UKMPG the importance of reducing the level of risk identified to as low as reasonably practical when conducting risk assessments, and the importance of ensuring that the effectiveness of any resulting control measures is reviewed regularly.
Reinforce to the members of the BPA and UKMPG the need to ensure a meaningful exchange of information between pilots and masters rather than merely the completion of a checklist. Such exchanges should cover all relevant areas such as the vessel characteristics, bridge team organisation and duties.
The MCA is recommended to:
Expedite and resource, through the national occupational standards working group of the PMSC steering committee, the requirement for national occupational standards for pilots to be a prerequisite for their recruitment and statutory authorisation.
Stolt-Nielsen Transportation B.V. is recommended to:
Review its safety management and auditing processes with a view to improving the safety culture among its ships’ crews, and encouraging a more open reporting regime.
Expedite its programme of bridge resource management training for its masters within its European coastal fleet, and ensure that pilot integration is included in the course syllabus.
Full report available on the MAIB website:
www.maib.dft.gov.uk/cms_resources/StoltTern.pdf
JCB
Rocknes Update 1
ROCKNES UPDATE
Following the report into the grounding of the Rocknes in the October 2004 issue of
The Pilot the following update has been reported in Lloyds List and Fairplay
“The Norwegian state mapping agency will now not be prosecuted following the sinking of the Rocknes, the bulk carrier that hit rocks and capsized near Bergen early last year with the loss of 18 lives. An investigation by state prosecutors found that the agency had published new charts of the area in 2003 that showed the rocks, and also published notice to mariners highlighting the danger. However, the prosecutors found that there had been a weakness in communication between the agency and the Norwegian Coastal Administration (NCA), which is in charge of pilotage.
The 26,000 dwt stone and gravel discharge bulker had a crew of 30 when it hit the rocks and capsized on 19 January 2004. An investigation by the Maritime Directorate found that the vessel had been unsafely loaded, which caused it to list sharply as it turned causing it to ground on the rocks due to its increased draught.”
Link to the original pdf magazine article (Page 10):
pilotmag.co.uk/userfiles/Pilotmag%20282%20(Jul%2005).pdf
Norwegian pilots issued with Portable Pilotage Units (PPU)
Further to the failings revealed by the Rocknes disaster the pilot was exonerated from any blame because he did not have the information on the rock and as a result the NCA has reviewed the manner in which it receives and promulgates information to its pilots and the result of the review is that all 270 pilots are now being issued with PPU. In choosing an appropriate system the NCA evaluated units from 15 companies and .nally decided on the “Pilot Mate” manufactured by the Norwegian company Maritime Information Systems (MARIS) which has been in use by UK Deep Sea pilots for the last two years. The PPU includes a fully certi.cated ECDIS which is automatically corrected over the Internet from a specialist correction company. In addition to the ECDIS the unit includes provisions to receive AIS data from the ship’s pilot plug and also includes a tidal program. Operational information includes advanced passage planning management, vessel database and a facility for the pilot to add his own notes to a particular passage. In use an alarm alerts the pilot to the stored route data which displays on-screen at the relevant position and the pilot can select other features such as grounding alerts related to the ship’s draft. All pilots will be certi.ed to use the PPU following courses based on IMO rules. However, the NCA have emphasised that the PPU will not replace existing pilotage practice but will provide the pilot with an additional resource designed to “improve the quality of service provided by the pilots”.
JCB
Karen Danielson
VTS FAILURE
Link to original pdf magazine article (Page 4):
pilotmag.co.uk/userfiles/Pilotmag%20281%20(Apr%2005).pdf
DANISH authorities are probing why a VTS system installed on the Great Belt Bridge to monitor shipping traffic failed to raise the alarm before the multipurpose container ship Karen Danielsen collided with the 18km suspension bridge early in March this year. The Danish Ministry of Defence’s Sovaernet confirmed that the VTS surveillance had failed as the 3,630dwt vessel headed off course into the lower western section of the bridge between the islands of Funen and Zealand. The chief officer was alone on watch at the time and was tragically killed in the collision and the Captain was hospitalised with several broken ribs, with three more crew suffering from minor injuries. All the Officers and crew were Croatian.
The Danish owned, Bahamas flagged,1985-built cargo vessel sustained major damage with the wheelhouse, foremast, funnel and cranes being ripped off as it passed beneath an 18 metre high western span of the bridge.
The accident was the worst ever since the bridge opened in 1998, leaving it badly damaged in one section but otherwise structurally intact.
An autopsy report on the Chief Officer revealed that he had at least 1.55 grams of alcohol in his blood and investigators said this level could explain the navigation error, The ship was travelling in ballast from the Fyn island to Finland, but failed to alter course and headed north instead of east and thus collided with the bridge.
The Danish coastal authorities admitted that this accident should never have happened because the Great Belt is monitored by radar and cameras which should immediately alert the authorities when a vessel leaves the shipping lane and gets too close to the bridge. The Danish navy’s operational command has admitted that it bore “some of the responsibility” for the collision since it had failed to alert the ship that it was heading straight for the bridge and they have indicated that this failure was due to human error.
This is the first case that I am aware of that has directly implicated a VTS system in a major incident and the subsequent enquiry will no doubt raise important questions over liability of VTS operators. With the increasing involvement of pilots in VTS centres many have expressed concerns over the potential liabilities which could arise, not just to the authority concerned but also individual operators, when a vessel is navigating in an area monitored by a port’s VTS. The outcome of this case could well have important implications for VTS and I will report on any developments as they become available.
JCB
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