Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
M2100
Initial 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.