The Australian Transport Safety Bureau (ATSB) issued an investigation report on the near grounding of the bulk carrier ‘Aquadiva’ in the Newcastle Harbour, NSW, on 12 February 2017. The report revealed that bridge resource management (BRM) techniques were not effectively implemented throughout the pilotage.
The incident
On 12 February 2017, the fully-laden bulk carrier, Aquadiva, was departing Newcastle Harbour under the conduct of a harbour pilot. At about 2218 Australian Eastern Daylight Time (AEDT), during Aquadiva’s passage through a section of the harbour channel known as The Horse Shoe, insufficient rudder was applied in time to effectively turn the ship.
The ship slewed, or moved laterally (sideways), toward the southern edge of the channel, and at 2224 it was over the limits of the marked navigation channel. Additional tugs were required to arrest the ship’s movement and return it to the channel to complete its departure.
Findings
…The harbour pilot’s passage plan was not provided to the ship’s crew prior to his boarding. As a result, the harbour pilot’s passage plan was different to that of the ship’s bridge crew’s. This meant they did not share the same mental model of the planned passage, and were unable to actively monitor the progress of the ship or the actions of the pilot.
As a consequence, the safety net usually provided by effective BRM was removed and the pilotage was exposed to single-person errors. Such errors, when they occurred, were not identified or corrected. When insufficient rudder was applied and the ship did not turn as expected, no-one from the ship’s bridge crew challenged or intervened to draw this error to the attention of the harbour pilot. Consequently, the ship traveled too close to shallow water.
- As Aquadiva commenced the 90° course alteration to port through The Horse Shoe, insufficient rudder was applied, and too late, to achieve the necessary rate of turn to successfully make the turn. As a consequence, the ship went off course, toward the southern limit of the channel, coming very close to grounding.
- During the early stages of the turn, the pilot was distracted from the primary task of monitoring and controlling the turn when he was likely focused on the rate of turn indicator and achieving the desired rate of turn. This short period of time was for sufficient duration at a critical point in the turn that control of the turn was compromised.
- A shared mental model for the pilotage was not established between the pilot, Aquadiva’s master and the bridge crewmembers. In particular, techniques such as:
-ensuring the same plan for the pilotage was shared by the ship’s crew and the pilot prior to the pilot boarding,
-utilising equipment such as the portable pilotage unit to assist explanation of the pilotage stages and parameters,
-ensuring active monitoring, challenge and response/intervention and error management techniques were used by all personnel involved in the pilotage,
were not used. Therefore, bridge resource management was not effectively implemented and practised. - Ambiguities and uncertainties around reporting requirements for port pilotage incidents led to delays in the ATSB being notified of the incident and commencing a safety investigation. These delays meant that volatile evidence such as the voyage data recordings were not able to be collected.
- The tugs returning from the successful departure of FPMC B Justice offered assistance to Aquadiva. Their assistance aided in preventing the ship from grounding.
Actions taken
As a result of this incident, the Port Authority implemented a training and information process with pilots to discuss the incident and its outcomes and to inform them of their incident reporting obligations. Also, procedures are to be updated to require the use of portable pilotage units on all pilotages, and a project to implement sharing of electronic passages plans is also being undertaken.
Aquadiva’s operator provided targeted training to the ship’s officers. The company also completed an internal investigation and circulated the report and discussed and implemented identified preventive and corrective actions throughout its fleet.
Lessons learned
Safe and efficient pilotage requires clear, unambiguous, effective communication and information exchange between all active participants. An agreed passage plan, its understanding and the establishment of a ‘shared mental model’ between a harbour pilot and a ship’s crew, forms the basis for a safe voyage. Without this, effective implementation of BRM techniques will be limited, removing the intended safety net provided by BRM and, in this instance, leaving the passage exposed to potential single-person errors.
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