The Britannia P&I Club has issued its latest edition of “Risk Watch”, in which includes an article that highlights lessons learned from an incident involving ships under pilotage.
The Club continues to see such incidents and highlights the importance of effective bridge resource management (BRM) during pilotage. In particular, the article written by Jacob Damgaard, Divisional Director, Loss Prevention Singapore, analyzed a case study in which, the master received information from the pilot regarding the planned berthing procedure, which included a 180-degree turn to port side.
Two tugboats were positioned on the starboard side of the ship, forward and aft. Before initiating the turn, the pilot informed the master that he believed the tugboats currently in use were underpowered for the intended manoeuvre. As a result, the pilot decided to rely on the main engine and rudder to assist with the turn.
The master then issued a command to turn the helm hard port. However, since the main engine was stopped, the ship did not respond to the helm. To compensate for this, the order was given to move forward at a slow speed while requesting the tugboats to apply maximum force in pushing the ship. Unfortunately, shortly after implementing these measures, the master observed the distance between the vessel and the jetty diminishing rapidly, indicating a high risk of collision. Consequently, the master ordered the ship to move in full astern and instructed the crew to drop the port side anchor. Regrettably, despite these actions, the vessel was unable to avoid making contact with the jetty.
From the above incident, four lessons learned were revealed:
#1 Master-pilot Exchange (MPX)
It was apparent that an effective MPX had not been conducted. Carrying out an MPX under time pressure may lead to insufficient information exchange and, in extreme cases, situations where various sections of the pilot card and the MPX checklist are not discussed and merely ticked to show compliance. A timely challenge from the master should assist in discussing the plan in sufficient detail and provide the opportunity to consider the risks and contingencies.
#2 Ineffective Intervention
The master also failed to challenge the pilot’s plan in the case study. The most common reason why individuals refrain from a safety intervention is related to personal concerns that the intervention may result in a defensive or angry reaction.
#3 Contingency Planning
Decisions taken without considering all available alternatives or operational limitations may turn out to be sub-optimal. This risk could be mitigated by an effective risk assessment and contingency plan.
#4 Detecting Insufficient Situational Awareness
While not applicable to the above incident, enhanced situational awareness can often be the difference between an incident occurring or not. Appropriate communication and rehearsed escalation practices should assist in detecting and addressing inadequate situational awareness.
