The Case Of The Unlucky Hooker Part Two

 

Ancient peoples believed that accidents happened
because demons lead people astray.
In the case of the Pasha Bulker they were right.

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Confirmation bias is a dangerous demon. It makes us look for evidence that we’re right and ignore evidence that we’re wrong. Another demon is pride, one of the seven deadly sins that devout Christians believe will lead to punishment, if not damnation. Then there’s that demon that so often infests the bridges of ships called fatigue.. Each of these demons was busy on the Pasha Bulker in May and early June 2007.

She was the unlucky hooker off the Australian coal port of Newcastle, New South Wales on the morning of 8th June 2007. Several other ships got into various degrees of trouble and the rest got away clear with little more damage than some hair-raising collision avoidance. Most of their masters took very similar decisions to Captain Park. They were just luckier.

How does Captain Park’s performance stack up against the other masters at the anchorage? Were they any better?

A survey by the Australian Transport Safety Board of 42 masters of vessels at anchor off Newcastle at the time showed that more than half had been master for more than five years, Captain Park had been a master for seven years.

There wasn’t much difference between masters who had been to Newcastle before except in one key comparison: of the 11 masters who had been to Newcastle five time or more, seven did not drag their anchors, about 64 per cent. Of the 20 who were first timers or had been there only once before 14 dragged anchor, 6, or about 30 per cent did not. Experience made a difference.

Only ten increased ballast as the weather worsened, 32, like the Pasha Bulker, did not.

In all, some 23 ships dragged anchor, as did the Pasha Bulker.

Except, that is, the seven who left the day before and kept their crew, their vessels and the environment safe.

Most of the remaining 49 ships only left when their anchors dragged and less than a third of ships took on extra ballast to deal with the extreme weather. Masters were reacting to events as they unfolded rather than setting criteria against which to take action, they were not pro-active.

It isn’t just Captain Park’s decisions we’ll look at but also how they were implemented using the bridge team and the resources available to him.

It has been said that Pasha Bulker was underpowered, but so are many bulkers. It may be why Captain Park wanted to ride out the storm at anchor, he was worried about the ship’s manouverability in bad weather.

It has been said that she should have had twin screws but as an old a grizzled seadog once told me, “Seafaring is about what you do with what you’ve got, not what you don’t do with what you don’t got.” That why these podcasts try to look at what could have been done practically at the time.

Time spent on reconnaissance is never wasted. The more you know about how to get where you’re going, what you’ve got to get there, and what’s going to be there when you arrive, the fewer surprises you’ll have. That’s what a passage plan is about, reconnaissance.

Poorly prepared passage plans are so common in maritime accidents that it’s probably true to say that of a ship has poor or incomplete passage plans there’s a very good chance that sooner or later it’ll come to grief.

Pasha Bulker’s passage plan was drawn up by the second officer in a format given in the ship’s safety management system. In addition to charts it should have listed the publications consulted, it didn’t. The port information section said nothing about the particular weather conditions at Newcastle, the exposed nature of the anchorage, the limitations of the holding ground, or the advice in the Australian Pilot to go to sea in event of a severe storm.

Captain Park didn’t sign approval of the passage plan and the Chief Mate didn’t sign that he’d read it. Not promising.

Later, Captain Park said that he’d consulted the charts and that Newcastle was a good anchorage with good holding ground. In fact, its an exposed anchorage where severe weather patterns tend to create a dangerous lee shore and where the depths make secure anchoring difficult in heavy weather.

Captain Park didn’t necessarily have to read all this up for himself. The second officer could have briefed him, that’s what teamwork is about, and it could have been covered in the pre-departure briefing in Japan, but that would have taken good bridge team management and, as we’ll see, that was in short supply.

Reconnaissance is about gathering information and Captain Park certainly did read one particular kind of information: The Australian Bureau of Meteorology weather forecasts. These predicted wind and wave heights but also warned that winds could be 40 per cent higher than expected and wave heights twice as high.

He based his decisions on the prediction but didn’t allow for the precautions and wasn’t actually aware of them.

That may be the demon of confirmation bias whispering in his ear. He made the decision to stay at anchor, Plan A. He was concerned about the ship’s performance in bad weather. When that confirmation bias demon gets to work we don’t make a Plan B, we look for confirmation that our decision is correct, we overlook evidence that our decision is wrong, we don’t review it.

Seeing other ships still at anchor as the situation worsened, confirmed his decision. When those ships dragged their anchors, he rationalised that his ship wouldn’t be affected because of the holding power of his anchor. Like others in the anchorage, he expected Newcastle VTIC to tell him when to up-anchor and take to sea, when it didn’t it confirmed his decision. As is usually the case, when the confirmation bias demon whipped off the blinkers and showed him he’d made the wrong decision, it was too late to do anything except enjoy the ride onto the rocky ledges off Nobby’s Beach.

Admiralty Class 14 amchor

Admiralty Class 14 anchor

Pride is another demon that can led us astray. Pasha Bulker was very new, Captain Park was proud of it. He believed in his anchor, an AC 14, a high holding power design, but it isn’t really the anchor that makes a ship stay put, it’s the mass of the anchor cable laying on the sea bed that does that.

The anchor should be flat on the seabed with its flukes embedded, attached to a long enough piece of anchor cable to stop the ship from moving much. From the end of the anchor cable laying flat on the on the seabed, the rest curves up to the hawse pipe in what’s called a catenary loop that acts as a shock absorber when the ship moves in a seaway, then to the windlass.

anchor on the sea bed

Anchor laying on sea bed

That’s why anchor cable is heavy stuff, in this case, grade 3 special steel. Each shackle, that’s a length of 27.43 metres or 90 feet, weighs 3.8 tonnes and she had twelve of them on each of the two anchors, that’s 45.6 tonnes of cable each, far more than the 7.425 tonnes of each of the anchors. And that, by the way, is a light weight cable because the AC 14 anchor has more holding power than the the traditional stockless anchor.

Newcastle anchorage does have a sand bottom which does make it a relatively good holding ground, but it is also quite deep. The amount of cable put out by Captain Park was a little more than sufficient to hold in calm weather, which is all that Admiralty recommendations cover, but not for the extreme weather conditions at the Newcastle anchorage. Anchoring successfully when the weather isn’t calm is a matter for the master’s skill and experience to determine, it isn’t a precise science. No ship can carry enough cable for all conditions.

Typical swing around anchor during high wind, can break anchor free

The ship’s Safety Management System required the master to specify limits on the wind, ship’s yawing and position and for an anchor watch checklist to be completed. According to the Australian Transport Safety Board report there were errors in the checklist that indicated that neither Captain Park nor the other ship’s officers understood several of the items. The ship’s SMS did not provide him with any specific guidance with regard to safely putting to sea in adverse weather or general guidance about the risks at a weather exposed anchorage.

Nevertheless, the Pasha Bulker’s anchor held while other vessels were dragging, apparently justifying his pride in his new anchors. Ironically, if he had been equipped with a lower holding power anchor it might have dragged earlier and he might have left the anchorage earlier.

He did not apparently consider putting down a second anchor that might have increased the ship’s security nor did he consider using an emergency drop-anchor to bring the ship’s head around when she was unresponsive and heading for Nobby’s Beach. An emergency drop anchor is a risky proposition, it can really mess up your windlass and isn’t something you would normally want to do, but these weren’t normal conditions.

That’s one of the reasons for having a Plan B, to remind yourself of the resources available to you, the resources you might forget if you’re trying to deal with things off the cuff.

Ballasting, or lack of it, was an issue. Why? It’s unlikely that he consciously thought much about whether it would put him on the vessel suitability list. He was aware of that issue, as were other masters, but that commercial pressure may have just been part of what coloured his decision.

There was plenty of advanced warning of the storm, so he had plenty of time to take on heavy weather ballast. He also had plenty of time to deballast after the storm – he wasn’t due to berth for another four days.

The ship’s stability book advised taking on heavy weather ballast in severe conditions but Captain Park may have felt these applied only when underway.

Taking on ballast in a storm isn’t a good idea. Water sloshing around in your tanks, and the free surface effect, doesn’t help your stability when you need it most. It’s the sort of operation you want to think about well in advance, pro-actively to avoid a hazard rather than trying to dealing with it on the run, so to speak.

Would heavy-weather ballast have change the outcome?

Would taking on heavy weather ballast have changed the outcome? Well, his propellers would have been fully immersed rather than continually breaking out of the water, so he’d have had more power at his disposal. Pasha Bulker would have had more steerage. The engine might not have cut out at a critical time. The effect of wind on his vessel would have been significantly less at a time when conditions were marginal. So you can make up your own mind about that one.

Also marginal was Captain Park’s performance. He was fatigued, he was overloaded when making critical decisions, and, sad to say, he lost the plot and made poor decisions at a time when it was too late to recover from them.

He’d had just two hours sleep, at most, in the previous 24 hours, which affected his performance when the ship and its crew needed him at the top of his game. He’d had only two hours of sleep because he didn’t use or encourage bridge team management. He was a one-man band playing out of tune.

Sometimes we like to think of ourselves as throwbacks to the days when men were made of iron and ships were made of wood. It’s a dangerous mentality today.

Just trying to bull through fatigue isn’t usually a good strategy. It’s better to manage it by pacing and using available resources. He’d have been better off to give the bridge team specific circumstances in which he should be called and gone to his cabin and rested, knowing that he would need his reserves of physical and mental energies when the storm hit hardest.

Later, he was trying to handle a constantly changing set of circumstances by himself while the rest of the bridge team stood by doing nothing because he didn’t give them a task, he didn’t give them leadership. He didn’t communicate with them and they didn’t communicate with him.

He could have assigned one of the mates to monitor the helmsman, which might have prevented an overshoot by a man who was undoubtedly doing his best. He could have assigned other mates, who were on the bridge, to monitor radar and the closeness to the coast, something that, in his overloaded condition, he wasn’t aware of.

There was no room on his bridge for a subordinate officer to challenge his decision and there should have been. Everyone on the bridge had been trained in Bridge Team Management, not one used it, even though each probably had a certificate of completion, it wasn’t encouraged.

That is, in fact, one of the demons that has taken residence in too many companies and on too many ships. The paper demon. Training, too often, isn’t about implementing what’s learned but about getting a certificate that you’ve done the course, a piece of paper with a signature on it. Only the paper demon knows that piece of paper is just so much toilet tissue unless the training is put into practice.

I stand to be corrected but if I was asked to pinpoint one specific, overriding cause for the Pasha Bulker grounding, it would be poor bridge team management. Yes, Captain Park made a number of errors of judgment and several poor decisions but bridge team management is supposed to trap errors. His company had clearly not impressed that upon him and hadn’t provided adequate training.

0824, and no functioning bridge team

So, beware of confirmation bias. Don’t look for things to confirm your original decision, look for reasons to change it.

Fatigue comes with the job. Learn to pace yourself and use the bridge team to ensure that you’re on top of your game when you need to be, because the guys on the bridge, and the rest of the crew, depend on you to bring them through without harm.

No matter how confident you are in Plan A, always have a Plan B and brief your bridge team so they know what to do if it has to be implemented.

Remember reconnaissance. The more you know, the fewer mistakes you’ll make.

And look at your own leadership style. Good leaders aren’t one-man bands. They succeed because they make good decisions based not just on what they know and think, but because they borrow what others know and think.

This is Bob Couttie wishing you safe sailing.

Relevant podcasts:

The Case Of The Errant Hookers

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