The Case of The Master’s Touch

 

Van Gogh

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Van Gogh was a painter with the master's touch ,
but this Van Gogh had a touch of a very different kind.
Lend an ear.

We're in Devonport, on the Mersey River, Tasmania, at 1800 on 23rd February 2008. Our ship is the 33 years old Marshall Islands registered Van Gogh. Originally built as a passenger and car ferry she was converted to a passenger ship in 1992.

Devonport, AustraliaNow she's 156.26 metres long, owned by Maritiem and Leasing, Bahamas and operated by Club Cruise Entertainment, of the Netherlands and classed as a 1A1 Ice-C Passenger Ship with Det Norske Veritas, DNV.

Let's visit the bridge. There are two two JMA ARPA radars, two JRC GPS units , a JRC JHS-180 AIS unit, a Consilium Marine echo sounder and a Consilium Marine M2 voyage data recorder. There's also a 'Navi Master' electronic charting system, the display of which is located in the forward starboard part of the wheelhouse.

If we look under the water we'd find two KaMeWa inward turning, controllable pitch propellers driven by two Pielstick 18PC2-2V-400 four stroke diesel engines which together develop 13 200 kW at 152 rpm although they are usually operated at 138 rpm giving the ship a service speed of about 16.5 knots. In the bow is a 600kW thruster.Van Gogh's screws

What about the rudders? Well, there's one, semi-balanced, mounted on the ship's centreline, which has a maximum angle of 35°.

Aboard Van Gogh are 414 passengers, now in the sixth week of a world cruise, and 226 crew, plus a harbour pilot, and she's about to depart. Berthed Just ahead of her is a large bulk carrier called Goliath.

She arrived from Freemantle Australia this afternoon five hours late due to rough seas. The weather is now fine and clear with a westerly wind at 11 to 16 knots but it's rained heavily over the past 24 hours so there's lots of fresh water pouring down the river to the sea and there's a strong ebb tide.

Departure preparations have been going on for the past four hours. Already, the mooring lines have been singled-up.

The harbour pilot's been aboard for fifteen minutes conducting the pre-departure exchange with the master, staff captain and first mate. They've agreed that the master will manoeuvre the ship off the berth and into the swing basin where the pilot will take over the conduct of the ship for the passage out of the port. They all agreed on the departure passage plan and the pilot and master have signed it.

For the departure, the ship will be in hand steering mode, with an experienced helmsman at the wheel. The first mate would, amongst his other duties, will monitor the helmsman and controlling the engine telegraphs when the master is no longer controlling the telegraphs directly from the bridge wing. The staff captain will relay orders from the master and pilot, when they are on the bridge-wings, to the remainder of the bridge team inside the wheelhouse.

Now, at 1800, engines are put on standby and the order's given "Let go forward, let go aft" and there's a flurry of activity on the deck as the mooring lines are gathered in.

At 1810, the master, using the controls on the port bridge wing, moves Van Gogh off the berth. As he does so the westerly wind increases, gusting to an estimated 20 knots. Two minutes later, he hands over to the harbour pilot to guide her out of the harbour and says: 'come ahead now captain'. The master moves both telegraphs to harbour full ahead. The ship's speed was about 2.5 knots.

Almost immediately, Van Gogh sets towards Goliath. The pilot realises that Van Gogh is not handling as he expected. He orders starboard 15° on the rudder shortly followed by a confirmation order of full ahead on both engines, and at 1813 with the ship at about six knots, the rudder is ordered hard to starboard.Van Gogh closes on Goliath

Van Gogh is closing on Goliath. The pilot orders one long blast on the ship's whistle. At about 30 seconds later Van Gogh's bridge passes abeam the bridge of Goliath, about 20 m off. Shortly afterwards, Van Gogh's port quarter is about 10 m off Goliath's midships, and a potential collision had been avoided, the pilot orders Van Gogh's helm to be put amidships.

The wash from Van Gogh caused a surge that moved Goliath forward and off the berth by around 5 metres and broke her forward spring.

At 1814, the pilot orders hard to port on the rudder and full ahead on both engines then hard to starboard. The pilot sees that the starboard engine telegraph lever are not in the same position as the port one. He again requests for full ahead on both the engines. Both levers are then moved to full ahead.

Van Gogh clears Goliath and the master and pilot moved into the wheelhouse. At about 1815, they move to the starboard bridge wing. From there they can check the ship's progress as it approaches the eastern shore. The pilot is worried that the ship will approach the eastern shore too closely, possibly grounding or colliding with a navigation beacon, known locally as the Wheeler Street beacon, located to the north of the passenger ferry berth.

As the pilot moves through the wheelhouse to the starboard bridge wing, he notices that the engine telegraph levers are not in the full ahead position as he had requested. He again asked for full ahead on both engines.

Just after 1815, with the ship's speed at almost nine knots on a course of 012° and to starboard of the line of the leading lights, the pilot, now on the starboard bridge wing, orders hard to port on the rudder. The ship approaches the Wheeler Street beacon.

The pilot orders hard to starboard to prevent the ship's stern from colliding with the beacon and to begin to bring the ship around the Police Point beacon and into the channel for the final leg of the outward passage. Immediately the helm is put hard over to starboard.

Just after 1816, when Van Gogh clears the Wheeler Street beacon, the pilot and the master return to the wheelhouse. The ship's speed is almost 10.5 knots and on a northerly course. The pilot thinks that the helm is amidships, contrary to his earlier order, again orders hard to starboard.

The ship does not respond and the pilot, again thinking that the helm is still in the midships position, orders hard to starboard for the third time.

It's hard for the pilot to know what's going on the bridge because everyone's talking in Russian.

The ship is not responding to the starboard helm order. The pilot now believes the ship will ground on the western bank of the river. Just after 1816 he orders full astern on both the engines and the master takes over the telegraph levers.

Dropping the anchor isn't an option because of the ship's proximity to a submerged sewer line.

The pilot knows the bank is soft and made up of sand and shale, and says to the master that if the ship does ground, 'we will come off and we will keep going'. The master replies 'OK'.

By 1817, the ship's speed has fallen to six knots. Just after 1817, at a speed of about one knot, Van Gogh briefly grounds in the vicinity of the leads near Regatta Point on the western shore of the Mersey River.

cctv image of the grounded vessel

Then, under the influence of the ebb tide and wind, the ship's stern starts to swing to starboard. To stop the swing, which would possible block the channel, the pilot orders full astern on the starboard engine, full ahead on the port engine and full starboard thrust on the bow thruster.

A little after 1818 the pilot orders the starboard engine stopped and the port engine to be left at full ahead. By 1820, the pilot has control of the ship and orders engine and helm movements to bring it safely back into the channel.

Van Gogh continues without damage or pollution on its world tour.

As he disembarks, the pilot tells the master: 'obviously, this has been a nonstandard departure'

The track of the Van Gogh

Indeed it was, but why? Was the bridge team really ignoring the pilot's orders?

Let's look at that propeller and rudder configuration.

To oversimplify: When a propeller turns it throws water behind it, a wash. If the rudder is in that wash the direction of the rudder turns the ship. In the configuration of the Van Gogh the propeller were either side of the rudder. The rudder is outside the wash. It wasn't the propeller wash that turned the ship, the movement of the ship itself relative to the water created the necessary pressure on the rudder to give steerage.

Traditional arrangement (left) and Van Gogh's screw/rudder (right)

Because of that configuration Van Gogh had sluggish steering, which the crew attempted to overcome by adjusting the engines to enhance the effect of the rudder during the departure. The master did not tell this to the pilot, who came to believe that they weren't obeying his instructions. In fact, they were interpreting his orders so that the effect of what they were were doing was the same.

Why didn't the pilot know about the vessel's sluggish manoeuvring? He was given the pilot card when he boarded, but the information wasn't on it and the pre-departure briefing did not include the ship's poor handling characteristics at slow speed, the minimum steerage speed or the fact that the ship had a tendency to turn up into the wind. The ship's manoeuvring characteristics diagram was posted in the wheelhouse, and showed that the minimum speed to gain steerage was four knots, the minimum manoeuvring speed was not discussed before the ship left the berth.

That devil of a word "assumed" crops up again: Since the pilot had conducted the vessel during the previous year the master assumed he was familiar with the minimum speed needed for steerage. Of course, if the master didn't give the information then the pilot should have asked for it, but there was nothing in the port's operating procedures to remind him to do so.

How useful would the information have been anyway? One essential bit of information not available to the pilot was the speed of the tidal current. The port was not equipped with anything to provide that data.

The vessel needed to make around four knots to have steerage. If the water was also moving at four knots in the same direction then the ship was effectively standing still relative to the water.

It's hard to steer when you're standing still.

At 1812, when Van Gogh's pilot told the master to come ahead on the ship's engines and she began moving towards Goliath, she was making good a speed of up to six knots, as much as four knots was due to the tidal outflow. The ship's speed through the water was only about two knots, significantly less than the minimum four knots required for steerage. Because the ship was moving with the water and not through it, there was little water flow past the rudder and the ship was not responding to helm orders.

If you're a regular listener you'll know that the issue of passage plans comes up time and time again in maritime incidents. In this case there was a passage plan, but it wasn't followed.

Comparison between planned and actual trackThe passage plan required Van Gogh to come off the berth and onto the line of the leading lights in the centre of the swing basin. That was the pilot's passage plan. Had it been followed the ship would have had sufficient sea room ahead of it to to build up speed through the water until there was sufficient water flow over the rudder to enable it to steer effectively.

True, a passage plan isn't graven in stone to be followed to the letter but if there is a departure from the plan then someone should be asking why. The pilot didn't say and the master didn't ask.

As it was, the large helm movements ordered by the pilot after pulling away from Goliath resulted in the ship overshooting the centreline of the channel and quickly moving towards the eastern shore of the river, the Wheeler Street beacon and the grounding.

Because of Van Gogh's poor manoeuvrability at low speeds, and in beam wind conditions, it was normal practice on the ship for 'hard over' helm orders to be 'augmented' by splitting the ship's engines to assist the ship to turn. The master and the bridge team did what they thought was best to fulfil the pilot's instructions with regard to manoeuvring the ship in the situation that they were faced with after clearing Goliath.

Splitting the engines works best as slow speed but at moderate speeds it is not an affective way to improve a ship's ability to turn. As she gains speed splitting the engines becomes less effective. The pilot on the Van Gogh may well have been aware of this but he didn't know the engines were being used that way.

While the pilot thought that the helm had been returned to midships shortly before 1816, the VDR data shows that the helm remained as he ordered at about 1815. It was only the propeller pitch settings which changed without his knowledge. The voyage data recorder showed that no one was changing the pilot's engine orders at the time he was giving them. While the pilot's orders/directions were not actually 'countermanded' at the time he gave them, they were certainly not followed.

Good bridge team management and bridge resource management is essential to making conduct of a ship under pilotage work. That didn't happen in the case of the Van Gogh.

Information wasn't being shared, no-one challenged decisions or situations that weren't planned or understood. The team, which included the pilot, didn't have a shared mental model.

So, how do you avoid this sort of situation?

Don't assume.

Let's start with the master-pilot exchange. Ensure that the pilot is aware of the ship's handling characteristics, do not assume he or she already knows them even if they've conducted the ship before.

If there are any special practices that the pilot might not be aware of, tell him about them. In this case it would have been helpful for the pilot to know that the engine would be used independently of each other to achieve the amount of turn requested by the pilot. It would have saved concern and confusion.

When things get busy, or a crisis occurs, it is tempting to lapse into one's own language without thinking about whether everyone else on the bridge understands. If someone doesn't understand what you're saying then they can't contribute to the safe navigation of the ship, they won't be intregrated into the bridge team, reducing situational awareness when it's most needed.

Make sure that everyone on the bridge speaks a common language and that the pilot is kept informed of what's going on. In this case, because the pilot only spoke English, all communications on the bridge should have been in English.

And keep asking yourself, do I know everything I need to know to carry out this manoeuvre, and if not, why not?

Of course, the incident could have been much worse, and often is when there's poor bridge team management.

Van Gogh was lucky. All she might have needed afterwords was a touch of paint.

This is Bob Couttie wishing you safe sailing.

Click here for the ATSB report

ATSB Report

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The Case Of The Confused Pilot

See Also

Moondance Grounding: Complacency and Communications

ATSB Report On A Reluctant Hooker – And A New Way To Explore

Kition vs I-10: Once More Unto The Bridge…

If Today’s Pilots Think They’ve Got It Tough…

Saga of disaster

Lessons From Sea Mithril’s Triple Touch On The Trent

Been There, Hit That – Communications Failures And A Clobbered Dolphin

Pilot Responsible For Cosco Busan – Pilot Commissioners

While We’re Talking About Pilots - Minerva Bridge Team Not In Concert

Useful:

The Pilot Magazine

The International Group Report On Pilot Error
The American Club’s new Video, Stranger On The Bridge

The Standard Club includes master-pilot issues in its free
Master’s Guide To Berthing

New Australian Pilotage Guidelines