The Nautical Institute draws lessons learned from an incident in which procedural dysfunctions and fatigue contributed to an undocking accident.
A tanker at jetty 1 was preparing to depart without a tug, despite concerns about the tide. The pilot, unaware of previous notes on the vessel’s weak astern power, planned to maneuver the vessel off the berth as the tide fell. At 04:00, the Master, worried about departing without a tug, hesitated but eventually agreed to proceed. As the vessel was maneuvered, the pilot issued multiple commands to control the turn.
However, the tanker began drifting toward jetty 2 due to the ebbing tide.
Attempts to correct the course failed, and at 04:47, the tanker collided with the westernmost dolphin of jetty 2. The vessel became stuck, with its stern resting on the jetty and its bow in soft mud, necessitating re-berthing assistance from two tugs later.
The pilot likely experienced fatigue during the boarding and departure, impacting his judgment and reaction time. Unfamiliarity with the new extension at jetty 2 further complicated the maneuver. Additionally, the pilot was unaware of the mandatory tug requirement for ebb tide departures.
Lessons learned:
- In this instance we can observe the near total collapse of Bridge Resource Management (BRM). On the one hand, the pilot was not properly supported in the manoeuvre by the bridge team. No one was assigned specific tasks. On the other hand, the Master, notwithstanding his misgivings about not employing a tug, acquiesced to the pilot’s misinformed judgement, although the pilot’s abilities were undermined by fatigue. Lesson for Masters – trust your experience, and delay departure if you have doubts.
- Incredibly, neither the pilot, the port duty officer, the VTS officer, nor the agent knew that an east-facing vessel in an ebb tide was required to have tug assistance for departure. How could we expect the Master to know? However, given the very restricted waters and strong ebb tide, normal seaman-like precautions would have dictated the presence of a tug.
