Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
M2118
Initial Report
The pilot boarded a logger vessel just before it entered the harbour. No defects were reported during the master-pilot exchange. As the vessel passed the breakwater, the pilot (now on the starboard bridge wing) ordered dead slow astern. The master relayed the order to the mate inside the wheelhouse, but the engine rpm indicator on the bridge wing continued to show ahead propulsion. Believing that either the master or mate had misheard the order to go astern, the pilot repeated the order. The master assured the pilot that the engine had gone astern but that the indicator on the bridge wing was wrong. As a precautionary measure, the pilot ordered the tugs to come to the vessel earlier than required, and the vessel safely berthed.
After berthing, the chief engineer came to the bridge and informed the master and pilot that the problem had been resolved. The pilot asked what the problem was, and the chief replied that there was a wiring problem inside the indicator. The pilot spoke with the master, reminding him he had not declared any defects during the master-pilot exchange.
CHIRP Comment
Before entering or leaving a port, all equipment must be tested to ensure that it is working as expected. Similarly, any defects discovered must be passed on during the master-pilot exchange.
CHIRP increasingly receives reports of masters unwilling to declare material deficiencies to pilots, which only come to light when the vessel does not manoeuvre as expected, thereby increasing the risk of a navigational incident.
Some masters fear that by declaring defects, they may be subject to a Port State Control inspection. Ironically, many pilots tell CHIRP that a vessel that proactively declares defects are likely to be viewed as having a good safety culture on board and, thus, is less likely to be inspected!
In some cases, commercial pressures are often in conflict with safety. The best place to undertake repairs is alongside where technical support and spare parts can more easily be sourced. If a vessel misses its scheduled departure because of the time to fix the defect, then this must be accepted as the safest option. This is preferable to losing control of the vessel and suffering catastrophic damage due to a breakdown because the defect was not fixed.
CHIRP encourages companies to drive proactive risk management throughout their fleets and to empower their masters and chief engineers to take positive safety actions to mitigate the risks. Prudent overreaction is always better. Ultimately, empowering staff to make bold decisions to remain in the harbour to undertake defect repairs is essential for ensuring the crew’s safety and the vessel itself. By fostering a culture of safety and open communication and providing the necessary training and resources, organisations can help ensure that all crew members are equipped to identify and address potential issues with the vessel promptly and effectively.
Key Issues relating to this report
Pressure – Companies should be aware that inappropriate pressure on crews to meet commercial deadlines compromises safety by impairing decision-making and hindering the timely and effective completion of maintenance or repairs.
Communication – To maintain navigational safety, masters must openly and transparently report any defects during the master-pilot exchange. Failing to do so jeopardises the integrity of pilotage operations.
Teamwork – Share the problems with your team and always encourage challenges to ensure the issues have been thoroughly considered. In report M2117, the issue was not fixed, and in the second report, M2118, the known problem was not communicated. Adopt a shared mental model when confronted with operational or technical problems.
Culture – Open reporting creates trust, whereas withholding vital information from the pilot can quickly erode trust.