US Coast Guard published its investigation report into the grounding of the cargo ship “Ever Forward” in the Chesapeake Bay, faulting the pilot tasked with helping the ship navigate the waterway.
The incident
On March 13, 2022, at approximately 1812 hours, the Hong Kong flagged containership EVER FORWARD departed Seagirt Marine Terminal in Baltimore, Maryland en route to Norfolk, Virginia. The departure time was slightly delayed due to challenges at berth securing the proper line handlers.
A Licensed Maryland State Pilot, hereinafter referred to as “Pilot 1,” was in direction and control of the EVER FORWARD from the point of getting underway until after the grounding.
Pilot 1 navigated EVER FORWARD using his PPU as the primary means of navigation. He was in the practice of intentionally not using any other navigation equipment while underway, citing a distrust of vessel equipment that was not his own and instances of equipment breaking while a pilot was using it.
Pilot 1 was positioned forward of the navigation console, port (left) of ship’s centerline, by the vessel’s pilot plug. The Third Officer (3/O) was positioned behind the navigation console, approximately at the centerline of the bridge. The Able Bodied Seaman (AB) was positioned at the helm, and the Deck Cadet (D/C) was behind the navigation console on the starboard (right) side. Bridge team members were generally in these locations but not restricted from movement for the duration of the voyage.
At 2010, the EVER FORWARD entered the Craighill Angle, and Pilot 1 ordered a heading of 161 degrees. The bridge team complied with the pilot’s order. At 2014, Pilot 1 viewed another screen on the PPU with the intent to screenshot data from another voyage. This action stopped the recording of the active transit, and the PPU did not begin recording the active transit again until 2019, after the vessel grounded and the pilot returned to the active screen.
At 2015, Pilot 1 sent a text message image of a previous voyage to another member of the Association of Maryland Pilots.At approximately 2016, Pilot 1 began drafting an email regarding issues he had encountered with facility line handlers. At 2017, the EVER FORWARD crossed the predetermined waypoint position to initiate a turn to approximately180 degrees. No order to turn was given by Pilot 1, and the Voyage Data Recorder (VDR) showed the vessel maintained a heading of approximately 161 degrees.
At approximately 2017, the Third Officer notified Pilot 1 that the PPU did not match the ship’s Electronic Chart Display and Information System (ECDIS). Pilot 1 put away his phone and began to use the ship’s ECDIS.
At 2018, Pilot 1 ordered 15 degrees starboard rudder, then ordered hard to starboard approximately 20 seconds later. The bridge team complied with both commands. At 2018, the EVER FORWARD grounded outside of the Craighill Channel.
Analysis
Pilot 1 stated that he solely relied on his PPU to navigate and did not use any ship’s equipment or charts. On March 13, 2022 at 2015 and while approaching a critical turn, Pilot 1 was taking a screenshot on his PPU of a previous trip to text another member of the Maryland Pilots Association in regard to an ongoing issue with line handlers.
Pilot 1 then began to draft an email on his cell phone in order to follow-up with a text message. The PPU operator manual states that the PPU automatically records all active vessel movements unless a replay of a previous trip is begun in the middle of an active trip.
The PPU will then stop recording the active trip and save the active vessel movement up until the point the PPU user navigated away from the active trip to view a previous one. It will then save that active trip into a file and start a new, separate file once the user returns to the active trip screen.
This means that there will be a data gap in the active trip for the duration of time that a user views a previously recorded trip. In this incident, Pilot 1’s PPU had two saved files with a gap in recording from 2015 to 2019, approximately the time that Pilot 1 stated he was viewing a previous recording to retrieve information to identify the line handler issue.
Since Pilot 1 stated that he used no navigational equipment aside from his personal PPU, and the PPU recording was gapped from 2015 to 2019, the evidence shows that for this duration of time, Pilot 1 was not actively engaged in navigating the vessel immediately prior to the grounding.
Additionally, during the EVER FORWARD’s outbound transit, Pilot 1 placed or received five phone calls from his personal cell phone. AT&T records indicated that the calls totaled approximately 61 minutes of the 126-minute voyage up to the grounding.
The longest personal call placed was over 55 minutes, starting at 1903 and ending at 1958. Pilot 1 also placed a work call regarding the line handler issues that had been previously encountered, something not urgent and unrelated to the current safe navigation of EVER FORWARD.
Further, he sent two text messages at 2007 and 2015, a critical time period leading up to when the turn south into the lower Craighill Channel should have been executed. The Third Officer observed Pilot 1 looking at his phone at 2017, approximately one minute before the vessel ran aground.
Although Pilot 1 did not disclose the purpose of all of the calls, he stated that due to the duration of time pilots are onboard vessels, it is not unusual to complete various personal tasks while underway.
However, when Pilot 2 was interviewed, he stated that he was not in the practice of making personal calls while in transit and would only feel comfortable doing so in an emergency situation.
Conclusions
The initiating event for this casualty occurred when the EVER FORWARD grounded. Causal Factors leading to this event were:
- Failure to maintain situational awareness and attention while navigating.
- Inadequate bridge resource management.
Recommendations
Following the incident, USCG concluded to certain recommendations, whose aim is to promote safety:
- Vessel owners and marine operators should develop and implement effective policies outlining when the use of cell phones and other portable electronic devices is appropriate or prohibited: This recommendation emphasizes the additional dangers associated with fixation on electronic devices as well as over reliance on a singular piece of equipment while navigating or performing safety sensitive functions.
- Vessel owners and operators should ensure and promote crew awareness of policies regarding the duties and obligations of officers on watch for the safety of the ship, even when a pilot is embarked: IMO highlights that efficient pilotage largely depends upon the effectiveness of communications and information exchange between the pilot, master, and bridge personnel regarding navigational procedures, local conditions, and ship’s characteristics. This information exchange should be a continuous process that is generally ongoing for the duration of the pilotage. In addition, Masters and bridge officers have a duty to support the pilot and ensure that his or her actions are monitored at all times. It is essential that these procedures are not only reflected in the vessel’s Safety Management System but also regularly used and practiced during transits with pilots on board.
- The Officer in Charge, Marine Inspection (OCMI) should initiate enforcement action for negligent operation of a commercial vessel: In fact, a person operating a vessel in a negligent manner or interfering with the safe operation of a vessel, so as to endanger the life, limb, or property of a person is liable to the U.S. Government for a civil penalty.
explore more at uscg’s investigation report
