Fog pic 1 web

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.


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



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


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.



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.

fog-pic-3-webSea Express 1 being towed to the Liverpool Landing Stage                             Photo: MAIB


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]


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.



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.

fog-pic-5The 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]


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]


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.



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,


• 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.


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]


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

One Response to “FOG & PILOTAGE”

July 25th, 2009 at 01:54

[…] of the Pilot which can be read at the fol­low­ing links: The unpre­ced­en­ted jail sen­tence of John Cota has set an alarm­ing pre­ced­ent […]


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