Lessons learned: Port safeguards bypassed, leading to vessel operating outside its capabilities

The incident

A ro-ro cargo vessel picked up a local pilot on a blustery day before embarking on a river passage that included the transit of a lock.

The pilot boarded early, and a master/pilot exchange was completed before they continued the river passage with tide and wind astern.

Unknown to the pilot and master, there were delays at the lock ahead as the vessel in front of them had requested a tug due to the weather conditions.

The pilot had not adjusted speed to account for his early boarding and, by the time they arrived at the lock, they had to turn to hold their position against the tide and wind.

Once the lock was clear, the pilot attempted an approach from his holding position but the vessel would not turn away from the wind and so he aborted his first attempt before completing a round turn and making another approach, this time with more speed.

The vessel continued to struggle against the wind and made contact with the outer lock wall at a speed of 2kts, resulting in superficial damage to the vessel and infrastructure.

Lessons learned

• Procedure: The port had comprehensive guidelines for the use of a tug at the lock. This was the first time the vessel had called at this port and, in view of the vessel’s manoeuvring characteristics and wind strength on the day, a tug should have been ordered, but was not. There were opportunities for the pilot to request a tug, namely when his frst approach to the lock had to be aborted, but this did not happen despite the tug’s immediate availability. The safeguards that the port had in place were bypassed, leading to the vessel operating outside its capabilities, the consequences of which could have been far more costly. Guidelines are there for a reason, and it pays to be cautious.
• Communication: The pilot boarded earlier than he was booked for good reason but did not then adjust the vessel’s speed during the river transit. When combined with the delay at the locks, this meant that the vessel had to turn head to wind and tide and hold position in a less than ideal place. At no point had vessel traffc services (VTS) confrmed arrival times at the lock or passed information about the delay to the pilot, and communications from other parties about tugs and weather conditions were made via mobile phones. Without a shared mental model built from open communication between VTS, the pilots and the lock operators, a hazardous situation was allowed to develop that could have been avoided with proactive management.
• Teamwork: The master/pilot exchange took place when the pilot boarded but salient information was either missed or not implemented during the approaches to the lock. The vessel’s pilot card stated that minimum steerage was achieved at 5 to 6kts through the water but, when considering the following tide, this was not achieved on either approach. The master/pilot exchange is all too often disregarded but is crucial to the integration of the pilot into the bridge team and their ability to safely plan and carry out manoeuvres.