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SAFETY4SEA

Lessons learned: All factors need to be taken into account when planning pilotage

by The Editorial Team
January 2, 2023
in Accidents
uk maib lessons learned

Credit: UK MAIB

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As UK MAIB informs a ro-ro cargo vessel suffered damage to the starboard propeller blades during manoeuvres off the bank and back into the channel.

The incident

It was late afternoon, conditions were calm, visibility was good, and a laden ro-ro cargo vessel was getting underway. The vessel that normally operated the trade route was undergoing scheduled maintenance and this temporary replacement vessel had an aft bridge superstructure. The route’s usual vessel was slightly smaller, more manoeuvrable and had a forward bridge superstructure.

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The master, C/O and second officer (2/O) were on the bridge for departure, along with another member of the company’s staff who held a Pilotage Exemption Certificate (PEC) for the harbour. A trainee pilot was also on board. The PEC holder regularly conducted pilotage on the usual vessel and was also familiar with the temporary vessel, having been on board during the usual vessel’s previous maintenance period.

The master manoeuvred off the berth then passed control to the 2/O, who was handling the vessel under the PEC holder’s direction. As the pilotage progressed, the PEC holder was explaining his plan to the trainee pilot.

The departure passage required a significant port turn in a constrained channel. The PEC holder used the alignment of familiar landmarks on the shore, sometimes referred to as natural transits, to determine the ‘wheel over’ point. When the PEC holder’s visual references aligned, the order was given for “Port 25 degrees”; this was almost immediately increased to “Maximum port wheel” as the PEC holder appreciated that the vessel was not turning safely in the channel.

The vessel’s stern swung to starboard during the turn and a significant vibration was experienced before the vessel came to a halt with the stern and starboard propeller aground. The starboard engine was stopped, and the master then used the port engine and the bow thruster to manoeuvre off the bank and back into the channel. The vessel was put into dry dock, where damage to the starboard propeller blades was discovered and repaired before the vessel returned to service.

Lessons learned

  • Plan: Local natural transits can be a very helpful guide to determine the position of a vessel during pilotage, and where helm orders should be given. However, all factors need to be taken into consideration when planning the pilotage, specifically the vessel’s speed and turning data as well as local environmental effects such as wind and tidal stream. In this instance, the PEC holder was applying the visual references that had been developed for the usual ferry but were simply not applicable to the temporary ferry with its aft bridge arrangement. This resulted in a late application of port wheel and then insufficient sea room to correct the error by tightening the turn, culminating in the grounding.
  • Teamwork: The personnel in a bridge team are just that – a team. When the vessel grounded, there were four deck officers and a trainee pilot on the bridge, all with various levels of experience and qualifications. The master had detailed knowledge of the vessel’s handling characteristics and the PEC holder and trainee pilot both knew the harbour well. Effective bridge teamwork requires that pilotage conduct is monitored and each other’s actions are checked, which was not evident in this case where the actions of the PEC holder went unchecked; no one challenged the plan or the late helm order for the port turn.
Lessons learned: All factors need to be taken into account when planning pilotageLessons learned: All factors need to be taken into account when planning pilotage
Lessons learned: All factors need to be taken into account when planning pilotageLessons learned: All factors need to be taken into account when planning pilotage
Tags: lessons learnedSafety DigestUK MAIB
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Comments 1

  1. Hans Hederström says:
    3 years ago

    First of all there must be a shared mental model consisting of an agreed upon detailed passage plan. Effective monitoring requires that quantitative limits to be established for each of the critical elements of pilotage. These limits should trigger the intervention (challenge) by the bridge team.
    In conclusion, the concept addresses the concerns raised by safety investigators around the world.
    An accident report of the Canadian Transport Safety Board maintained that “the absence of a detailed, mutually agreed-upon passage plan deprives bridge team members of the means to effectively monitor a vessel’s progress, compromising the principles of Bridge Resource Management”.

    Reply

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