Adam Parnell
FEEDBACK
PH01
Unlocking the safety potential of ports and harbours
As avid supporters of maritime safety, we are well aware of the unique challenges faced within ports and harbours. Congested waterways, filled with vessels of all shapes and sizes, navigating in close quarters with limited maneuverability, and operating within strict time constraints present an intricate safety puzzle. However, within these challenges also lie tremendous opportunities.
For years, ports have served as hubs for information exchange, fostering collaboration and knowledge-sharing among seafarers, with a particular emphasis on safety. After all, as the age-old cliché goes, it’s better to learn from the experiences of others since we don’t live long enough to have them all ourselves! And that’s precisely why we’re here.
Celebrating our 20th anniversary, CHIRP has been an active participant in these crucial conversations. Whether it’s engaging with individual mariners through our confidential incident reporting program or disseminating valuable insights via our FEEDBACK newsletter series, CHIRP has been dedicated to enhancing maritime safety. And now, we are thrilled to announce the launch of a new series of newsletters specifically tailored to ports and harbours for three specific reasons. Firstly, we aim to raise safety awareness among individuals by providing them with vital education and knowledge. We believe that education is empowerment when it comes to maritime safety.
Secondly, we strive to create a platform for organizations to share their knowledge and best practices without compromising their commercial or reputational interests. By encouraging the exchange of valuable insights, we hope to foster a culture of continuous improvement in safety measures across the industry.
Lastly, these newsletters provide an evidence base for decision-making bodies by highlighting recurrent themes and addressing the underlying causes of incidents. By removing information that identifies individuals, organizations, or specific locations, we shift the focus from the “who” to the “what” and “why” of each incident, enabling us to identify key patterns and develop effective preventive measures.
We sincerely hope that you find this new series engaging, interesting, and, most importantly, helpful in your daily operations. Your feedback is invaluable to us, so please don’t hesitate to share your thoughts by contacting us at mail@chirp.co.uk or through your incident reports. Together, we can continue to make ports and harbours safer for everyone involved.
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M2062
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Contingency action to avoid a close quarter incident with a passenger Ferry
Contingency action to avoid a close quarter incident with a passenger FerryInitial Report
Our reporter, a passenger ferry captain, writes: “As per the timetable, we arrived at the standby location for the port at the required time. It was daylight, with good visibility and a stiff wind. We worked, as usual, on the pre-arrival checks and verifications as we closed on the berth. When I called the port per the pre-arrival checklist, I was informed that a large passenger liner had just let go and that I might have to ‘slow her up’ (referring to my vessel). However, given the proximity to the berth, the other boat and the increasingly confined waters, it was clear that I would have to lose speed quicker than I safely could. So, I had to opt for a rapid turn upwind (to avoid being set onto the nearby lee shore). I continued my turn and completed a 360, and during this time, the passenger liner was clear of the port and the berth we were aiming for. Our distance from the breakwater was approximately 3 cables when we started the turn.
For each port of arrival, we plan two abort positions. We had passed the first, where ‘Standby’ is rung on, the crew called to stations, pitch response is verified, and hand steering is engaged. We had not yet reached the second abort position (approximately four cables from the first), so a direct abort was still viable.
Shortly after passing the first abort and confirming the items mentioned, I called the harbour for permission to continue into the berth. I was given the all-clear whilst being advised of a departing cruise ship that might be leaving. The operator told me I “might want to slow her up a bit”, but it was now clear to me that I would need to abort the arrival to avoid a close-quarters situation with the cruise vessel, which was manoeuvring off her berth. Given the proximity of the lee shore to starboard, I elected to turn to port/upwind and gain distance from the shore, together with slackening speed to a minimum.
With the above avoidance measures well underway and having the desired effect, I communicated with the cruise vessel to establish which general direction they intended to take upon clearing the harbour to allow me to plan the rest of my manoeuvre and not result in additional unnecessary risk. With them advising a course to the east initially before turning to the north, I elected to complete a full 360, allowing time and space for the cruise ship to exit the immediate harbour area and for me to generally pick up the standard approach to our berth for arrival.
The main hazards were the proximity of the lee shore, with easterly winds, something that is factored into the passage plan to allow extra room, including the shoaling waters to the south of the berth; this knowledge allowed me to decide on early, positive and bold avoidance measures quickly, rather than allowing the risk to increase by proceeding onwards, even at a reduced speed, and allowing an unnecessary close quarters situation to develop.
As my vessel is on a timetabled service, we arrive and leave at the same time every day, weather permitting. Despite this, the cruise ship was allowed a departure that directly clashed with our arrival. A clash in movements such as this should have been avoided with a simple telephone call or email. After that, we could have timed our arrival later, thus preventing the situation above entirely.
It’s worth noting that the bridge team worked very well together in the initial arrival, the abort actions, and the passage/arrival resumption and subsequent safe berthing.
CHIRP Comment
The ferry traded time for space and safe water and avoided a close-quarters situation. This was the correct course of action. Readers are encouraged to compare this with report M2036, published in our last edition of FEEDBACK, which highlights the perils of taking the opposite approach.
Port authorities are responsible for managing vessel traffic, and they would have been aware of the ferry’s scheduled arrival time. Cruise vessels too operate to an itinerary but better co-ordination between the port and the cruise ship would have avoided this incident. This suggests either a breakdown in communication or the ferry’s arrival was not correctly considered when the cruise ship planned its departure time. Radio procedure by the port authority was also ambiguous: was “You might want to slow up” a direction, or a recommendation?
In smaller ports, particularly those which are not staffed 24 hours a day, publish notices to mariners directing certain sizes or categories of vessels to broadcast their arrival and departure on the port’s VHF working channel. This alerts other vessels of traffic in their vicinity and allows them to co-ordinate with each other. CHIRP encourages small ports to consider whether such a scheme would be appropriate in their harbour.
Key Issues relating to this report
Local Practices- Port management must not leave marine operations to chance. Establish clear safety risk measures, and define procedures to clearly understand what is required for arriving and departing vessels at this port.
Communications- Clear communications from the port authority, which prioritises incoming and outgoing vessel traffic, should be established, especially in ports with limited room to manoeuvre.
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M2070
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Mooring launch crushed against the side of a container vesselMooring launch crushed against the side of a container vesselInitial Report
The port berthing officer was attending to a large container vessel’s berthing when he received a radio message from the mooring team to quickly head aft to investigate a serious incident during mooring operations.
The aft mooring launch sat at the stern of the containership, waiting for the third line to be lowered to them. Instead, the two lines that had been run ashore and were fast on the bollards were slackened off by the aft mooring team and dumped into the water. The launch tried to move away from the lines to avoid getting tangled. When the launch was almost clear, the ship heaved up on the two lines again, only to catch the mooring launch, lifting it out of the water and crushing against the underside of the ship’s flare. The two launch crew considered abandoning the craft, as the prolonged shouting and blast of their horn did not affect getting the crew’s attention. Finally, the ship’s after mooring crew realised what had happened and slackened off the lines. Other than the boat crew being severely shaken by the incident, there were no injuries to the crew but some damage to the mooring boat.
CHIRP Comment
This is an obvious case of miscommunication during a critical phase of the mooring operation.
Vessels often pay out lines to take the weight off them prior to transferring them to the working drums. The safest method is to do this only after all lines are ashore, and then moved one at a time, so that the lines and the vessel always remain under control. CHIRP wonders if there was a real- or perceived-time pressure on the mooring party for them to take such a dangerous short-cut?
Key Issues relating to this report
Situational Awareness– While launches or other vessels such as tugs often make line handling easier, it complicates the mooring officer’s task because they must simultaneously retain an awareness of what is happening on board as well as over the side. It is rare that a vessel has enough crew to dedicate one person to each of these tasks, although that would be ideal. Instead, additional care must be taken when working lines with vessels nearby.
Pressure- Mooring operations must never be rushed. Care is required by the master and pilot to provide timely messaging to the mooring teams to ensure that each order is carried out carefully and in an unhurried manner.
Distractions- The mooring team were distracted when they failed to hear the mooring boat crew’s alert when they were trapped against the ship’s hull. Keeping alert during mooring operations is vital, given the changing nature of the ship’s movement and the strain on the mooring lines.
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M2100
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Vessel grounds in harbourVessel grounds in harbourInitial Report
The pilot boarded a very large container ship at 0200 before it navigated into harbour. The wind was NNE 10 knots, the tidal current was to the SE, and visibility was good. The pilot noted after the incident that language difficulties reduced the effectiveness of spoken communication.
At about 0350 (1 hr and 30 mins after high water), the container ship commenced her swing to port off the berth. By 0405, with the swing completed, the vessel appeared to be setting south under the influence of wind and tide.
The vessel’s stern swung towards the quay and got close to one of the jetty cranes, so the pilot manoeuvred the vessel to avoid contact. They needed someone to report distances to the quay and other infrastructure as it was less than 10m from the jetty and a mooring dolphin. Three tugs were directed to pull the container ship away from the jetty, but it became apparent that the vessel had drifted due to wind and tide and had grounded on a charted shallow patch. The port authorities were informed, and a fourth tug was despatched to push onto the vessel’s port quarter. With this assistance, the ship safely manoeuvred off the shallow patch at 0506 and subsequently berthed without further incident after extensive checks on the hull’s watertight integrity.
CHIRP Comment
Maintaining situational awareness at night is challenging. Visual references are difficult to make out, particularly against background lights, and they can change over time due to development ashore. IMO SOLAS Chapter V regulation 13,
Establishment and operation of aids to navigation should be reviewed for each port as the volume of traffic justifies and the degree of risk required
As part of the assessment, port authorities must consider whether their navigation aids are sufficient to enable safe navigation, including appropriate lit aids to navigation if the port is open at night. To determine which aids are required, countries and port authorities must conduct risk assessments of their ports. IALA guidance (G1124) provides a guide to safety assessment.
The briefing between the pilot and crew was hampered by language difficulties. The pilot became the ‘single point of failure’ as a result. A sketch or other visual aid would have helped develop a common understanding, making it easier to identify when the pilot needed assistance and to prompt constructively or question, e.g. “Are you aware that we are drifting towards the shallow patch?” This did not happen. As the vessel moved close to the jetty and other objects, the pilot’s workload focus increased, and they lost overall situational awareness.
CHIRP strongly encourages teams to adopt the PACE (Probe, Alert, Challenge, and Emergency) described in some depth in the CHIRP publication ‘Making critical decisions at Sea’, which is available on our website. Good communication and attention are essential, particularly at night when our circadian rhythms are often at their lowest.
CHIRP draws your attention to the enormous forces acting on the underwater hull of very large vessels. Masters responsible for safely navigating very large vessels should be provided with adequate training in handling these large vessels so that they can, with enhanced knowledge, assist the pilots in safely berthing the vessel.
There are a number of manned-model courses which train masters and pilots in understanding the dynamic forces acting on the hull of all types of vessels.
Key Issues relating to this report
Communications – The bridge team should have affirmed the pilot’s actions when requested. A drawing of the intended plan would have provided a visual interpretation of the stages of the turn with safe clearing distances applied to the radar for cross-checking.
Alerting – Only the pilot appeared concerned about the vessel’s movement towards the corner of the jetty. The pilot stated he was acting alone- does this happen on your ship? Do you provide the support the pilot needs?
Fatigue/Situational Awareness – It’s possible, given the time of day, that elements of fatigue were apparent. Berthing or unberthing at night requires enhanced situational awareness of yourself and your surroundings. Actively seek input from others.
fatigue, loss_of_awareness, poor_communication -
M2103
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Workload distractions lead to a high-speed collisionWorkload distractions lead to a high-speed collisionInitial Report
As a Crew Transfer Vessel (CTV) was returning to port at high speed, the master became distracted by a lengthy radio conversation and did not notice that the vessel had been pushed off course by the tide. It collided with a wind turbine tower at speed, causing significant damage to the vessel. The weather and visibility were good. As is common for vessels of this length, only the master was on the bridge; nobody else was keeping a lookout during the radio exchange.
CHIRP Comment
Unfortunately, this is not an isolated incident: CHIRP is aware of several incidents where vessels collided with charted objects when the sole person on the bridge became distracted by workload.
Single bridge manning is common, particularly on small to medium-sized vessels by day in good visibility. However, manning requirements must always be informed by rigorous risk assessment. In the case of single bridge manning, extra care should be taken to ensure that the risks of workload, fatigue, distractions and other factors are adequately reduced to as low as reasonably practicable. The routine nature of this type of operation can lead to low mental arousal and risk distraction. This ‘risk normalisation’ reduces concern and can lead to overconfidence.
CHIRP was unsure if the ECDIS was working and correctly configured and could not determine from the report if any warning was sounded or heard.
Consideration should be given to increasing the number of lookouts during high-speed transit operations. Utilise your crew to highlight perceived hazards in the wind farm zones and use all navigational aids to assess the risks, especially on the chart plotter (alarms for off-track limits/cross-track error and radar guard zones).
Management should consider conducting a thorough risk assessment for vessels under their management using an independent auditor to determine the risks and set appropriate levels of manning for critical stages of a CTV operation.
Key Issues relating to this report
Situational Awareness – The master did not notice that the CTV had drifted off track. The offshore sector is a challenging and busy environment. What steps does your company take to ensure that this incident could not happen?
Capability – Is the resource capability adequate to ensure that safe navigational capability is maintained? The wind farm industry is relatively new, and an assessment of the risks associated with maintaining and servicing the wind turbines should be considered for review.
Distractions – Maintaining focus on a repetitive job is challenging. Having a lookout in place changes the dynamic interaction on the bridge, which can lead to a greater focus on hazard awareness.
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M1877
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Fall from vertical quayside ladder has near-fatal consequencesFall from vertical quayside ladder has near-fatal consequencesInitial Report
A fisher returned to their vessel with a guest in the late evening after they had met ashore. Both had drunk alcohol. It was low tide, and the vessel was approximately 6m below the quay edge due to the tidal range in that port.
As they climbed down the vertical quayside ladder, the guest fell off the ladder and hit the vessel’s hull before falling, injured, into the water. The sea temperature was approximately 10° C (50° F).
The fisher was unable to recover the person in the water and entered the water himself in an attempt to keep the guest from drowning.
A crew member from another fishing vessel moored nearby heard the commotion and managed to recover the injured person and the crew member from the water back onto the deck of the fishing vessel. Due to the effects of the cold water and the injuries, the guest was unresponsive and not breathing.
The port authority’s security team called an ambulance and commenced CPR on the casualty until the emergency services arrived, but it took over an hour to lift them from the vessel and up the 6m to the quayside and into the ambulance where they made a full recovery within a few days.
Due to the range of the tide the vessel did not put out a gangway and instead relied on the vertical metal ladder secured to the quay wall. At low tide this generated a significant risk of falling from height and onto the steel deck of the vessel and/or into cold water.
Design (latent factor) – Vertical ladders are exposed to the elements and prone to damage by vessels berthed alongside. There is no fall protection inherent within the design and unless regularly maintained they are prone to rusting and marine growth
Fit for duty – Alcohol increases the likelihood of an incident occurring and CHIRP recommends that Safety Management System (SMS) risk assessments include alcohol/intoxication as a factor when appropriate, particularly in cases where access arrangements include a climb up and down vertical ladders.
Local practices – CHIRP acknowledges that high tidal ranges preclude the use of gangways, and that many ports lack the space, water, and money to install pontoon berths, so must therefore rely on the use of vertical ladders as the safest means of access.
Is there a shared understanding between the port authority and the vessels regarding who is responsible for providing the means of safe access? This can vary by country and regulatory area. Does your vessel adhere to the local regulations?
Culture – To be effective, there must be a shared safety culture between vessels and port authorities, particularly where regulations on the provision of a safe means of access can be interpreted differently by the port authority and a vessel’s Master. Port safety forums are one way of developing this shared safety culture with everyone working to a shared understanding of risks and their control measures.
Capability – Do ports have the correct equipment to facilitate recovery of a casualty from a vessel at low tide, and is this operation regularly practised?
Report Ends……………………
CHIRP Comment
The Master is responsible for ensuring a safe means of access to their vessel. This can be difficult, especially for small vessels that lack the space on board to carry or rig a gangway, or where the tidal range would make the gangway too steep to safely use. In these cases, Masters consider that they have no option but to use the vertical ladders as the only means of access or request a more suitable berth. By contrast, many port authorities view the vertical quayside ladders as ‘self-rescue’ equipment for anyone who falls into the water. They do not consider them as a safe means of access onto vessels, especially those that lie some distance below the quay edge at low tide. The rules that determine whether it is the port authority or the master that is responsible for providing safe access onto vessels vary by country and are not always clear. CHIRP urges regulators in those jurisdictions to reduce the scope for different interpretations wherever possible.
The need to recover casualties from vessels at low tide is reasonably foreseeable, so ports are strongly encouraged to conduct thorough risk assessments to deal with this scenario and develop an emergency recovery plan. This might require the purchase of specialist equipment or the nomination of a suitable ‘casualty recovery’ berth.
Ports and vessels’ masters are also encouraged to ensure that visiting crews are aware of the local arrangements for summoning emergency assistance and can describe their location to the emergency services when doing so.
Key Issues relating to this report
Design (latent factor) – Vertical ladders are exposed to the elements and prone to damage by vessels berthed alongside. There is no fall protection inherent within the design and unless regularly maintained they are prone to rusting and marine growth
Fit for duty – Alcohol increases the likelihood of an incident occurring and CHIRP recommends that Safety Management System (SMS) risk assessments include alcohol/intoxication as a factor when appropriate, particularly in cases where access arrangements include a climb up and down vertical ladders.
Local practices – CHIRP acknowledges that high tidal ranges preclude the use of gangways, and that many ports lack the space, water, and money to install pontoon berths, so must therefore rely on the use of vertical ladders as the safest means of access.
Is there a shared understanding between the port authority and the vessels regarding who is responsible for providing the means of safe access? This can vary by country and regulatory area. Does your vessel adhere to the local regulations?
Culture – To be effective, there must be a shared safety culture between vessels and port authorities, particularly where regulations on the provision of a safe means of access can be interpreted differently by the port authority and a vessel’s Master. Port safety forums are one way of developing this shared safety culture with everyone working to a shared understanding of risks and their control measures.
Capability – Do ports have the correct equipment to facilitate recovery of a casualty from a vessel at low tide, and is this operation regularly practised?