Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
M2048
Initial Report
A vessel was entering harbour by day with a pilot on board. After settling on a course of 168°, the pilot asked for a new course of 170° to set up for a wide turn onto the next (160°) leg.
The helm correctly repeated back the 170° course to the pilot who then looked down at their portable pilot unit (PPU). When they looked up, they saw that the ship had started to swing to port. The master and OOW challenged the error just as the pilot realised what was happening, and the swing was quickly stopped.
One possibility considered by the pilot was that the helm might have had the next (160°) course in mind which was to port. Visually too, there was a shoal beacon fine on the starboard bow and the helm might have intuitively turned to open the distance from that navigational hazard. The pilot put the incident down to being human factors slip, which he felt reinforced the need to check the rudder indicator with all course changes.
CHIRP Comment
The pilot is commended for self-reporting; a sign of a strong safety culture at that port. Similarly, the use of closed-loop communication by the pilot and helmsperson, and the swift challenges by the master and OOW indicate a strong safety culture among the crew, too.
Several environmental stressors can affect how the helmsperson responds to helm orders. Creating the right communications environment with good clear, concise communications will significantly help the helmsman interpret the orders correctly. Providing advanced intentions of helm action at critical points in pilotage assists the bridge team in anticipating the pilot’s action. In this instance, the clearest order would have been “Starboard wheel, steer 170°.” To further minimise the risk of confusion, some pilots augment their spoken orders with non-verbal signals such as raising an arm or pointing in the desired direction. This is good practice and one that CHIRP encourages OOW and other pilots to emulate.
CHIRP remains the confidential, independent and impartial voice of the mariner, whose safety remains our priority.
Key Issues relating to this report
Communications- Ensuring that the spoken message has been received and understood and the desired outcome implemented is crucial during navigation manoeuvres. Different pilots and different bridge teams will all do things slightly differently. Ensuring that there is closed-loop communication at all stages of pilotage for helm and engine orders creates consistency and will improve navigational safety.
Alerting- Keeping the bridge team informed of current and future intentions reduces the risk that others will anticipate or misinterpret orders. This is particularly useful in times of high or low workload.
Teamwork- The master and the OOW reacted swiftly to the error; this shows a commendably high level of teamwork. Pilots often have many jobs during the day can feel tired and make the occasional slip, and it is at these moments that they need the back-up and support from the bridge team. When you are on the bridge of your next ship, consider how well you work as a team and what you can do to improve bridge teamwork. Does your bridge team ever conduct a post-arrival/departure debrief?