May 092009
 

What, you might wonder, would bring together the NTSB, the IMO, the contact of  the Cosco Busan with the San Francisco-Oakland Bay Bridge and a senior loan officer at a bank in Spokane, Washington, having sexual relations with a Mallard duck?

The NTSB has just released the full report of the Cosco Busan incident and among the issues is that of communications, problems of which are involved in about one in five maritime incidents.

That’s why it is good practice to confirm that information has been understood and that its importance is appreciated.

On the Cosco Busan the voyage data recorder recorded the following conversation between the Pilot and the Master:

Pilot:  “What are these… ah… red [unintelligible]?”
The master responded, “This is on bridge.”

The pilot then said to the master, “I couldn’t figure out what the red light… red… red triangle was.”

The Pilot took this to mean that the red triangles marked the centre of the span when, in fact they indicated the buoys marking the bridge support which the ship later hit. The Master did not realise the importance of the question.

Later, as things unravelled:

Pilot: [unintelligible] you said this was the center of the bridge.
Master: Yes.
Pilot: No, this is the center. That’s the tower. This is the tower. That’s why we hit it. I thought that was the center.
Master: It’s a buoy. [unintelligible] the chart.
Pilot: Yeah, see. No, this is the tower. I asked you if that was [unintelligible]. . . .
Captain, you said it was the center.
Master: Cen… cen… cen… center.
Pilot: Yeah, that’s the bridge pier [expletive]. I thought it was the center.

Says the NTSB report “Shortly after this conversation, the master can be heard saying, in Mandarin, “He should have known—this is the center of the bridge, not the center of the channel.”

In many Asian cultures ‘yes’ does not necessarily mean an affirmative, oner can pick from a range of meanings that would not naturally occur to a Westerner.

(The curiosities and confusion of language are touched upon in Bob Couttie’s new, lighthearted book, Chew The Bones, which you can buy from Amazon and the proceed of which will help support MAC)

In a recommendation letter to US Coast Guard commander Thad Allen the NTSB wrote: “The Safety Board therefore recommends that the Coast Guard propose to the IMO that it include a segment on cultural and language differences and their possible influence on mariner performance in its bridge resource management curricula.”

It’s tempting to think that closely allied languages like English and American present less opportunity for confusion, but you would be wrong. Take this example from Snopes’ wonderful Urban Legend site:

“Armstrong proceeded to shag ducks…”

You can read the rest of the story here. While mallards are known to have a somewhat ‘out there’ sex life, sex acts between humans and 10 days old ducklings are further out than most would want to go.

Apparently ‘to shag’ in American means to catch baseballs, to us Brits it has a rather different connotation.

The lesson is clear: communication is transmitting information, receiving information and understanding information. It’s vital to double each each part of that process, that the communication is understood and verified.

Otherwise, you could end up being shagged by lawyers, and not like a duck.

Nov 012008
 

Kition: Back one turn...

As lawyers fiddle in their briefs in preparation for the trial of San Francisco pilot John Cota, another bridge contact incident has come under the spotlight with the release of the US National Transportation Safety Board’s report on the Panama-registered 243 metre tanker Kition – Interstate Highway 10 bridge pier incident on 10 February 2008. Loss of situational awareness, poor judgment and a hazardous manoeuvre by the pilot, Captain J. Strahan jr., led to the accident, concludes the report.

It was the pilot’s first time to take a ship from the Apex Oil terminal on the west bank of the Mississippi River at Port Allen, Baton Rouge, Louisiana. He had never been involved in an incident involving pilot error since becoming a pilot in 2002.

The vessel was moored port side to with the bow facing upriver. On departure she would have to be turned to face down river. Due to the hazards represented by the bridge pier, warnings are given in the Coast Pilot, normal pracrice is to either drop down through the bridge and turn the ship or go about a mil upriver to a former ferry landing to turn. Instead, the pilot turned the vessel off the dock. As he did so the ship swung to starboard and hit the I-10 bridge pier.

Damage to the bridge is estimated at $8m and to Kition, $726,500. Incidents involving ships under pilotage average $850,000 in insurance settlements.

Several lesson arise from the incident: Captain Strahan did not usually volunteer his manouevering intentions to ship’s masters unless they asked, a poor practice. Inadequate master-pilot exchanges are a signature of poor bridge resource management in incidents nvolving vessels under pilotage. While the lack of an adequate exchange may not lead directly to an incident they do indicate underlying systemic problems which increase the chances of an accident.

So, always ask a pilot what his intentions are and go over his passage plan. The master-pilot exchange establishes the bridge team relationship necessary for safe navigation.

An earlier report by the New Orleans Baton Rouge Steamship Pilot’s Association, which has oversight of pilots, also identified ineffective communications between the pilot and the attending tugs and failure to readjust his decisions s cirsumstances changed.

An important of situational awareness is evaluating how changing circumstances affect decisions already made and adjusting to those changing conditions. It is a dynamic process. What often happens is that, having made a decision one stays with it and over-looks or rationalises conditions that conflict with that decision.

It is important to continuously compare what is happenoing in a changing situation to the decisions made.

Oct 262008
 

Captain John Cota, the pilot aboard the Cosco Busan when it made contact with the Delta tower of the San Francisco-Oakland Bridge on 7 November 2007, has been found responsible for the accident through misconduct. Some 120,000 litres of bunker were spilled, the ship suffered a 70 metre by four metre gash in its hull. Six crewmembers of the Cosco Busan have been detained without charges since the incident pending a criminal trial scheduled for November in which Cota and the ship’s manager, Fleet, are to be defendants.

The Incident Review Committee of The Board of Pilot Commissioners For San Francisco, San Pablo and Suisun, concluded that Captain Cota, prior to getting underway, failed to utilize all available resources to determine visibility conditions along his intended route when it was obvious that he would have to make the transit to sea in significantly reduced visibility; That he exhibited significant concerns about the condition of the ship’s radar and a lack of familiarity with the ship’s electronic chart system, but then failed to properly take those concerns into account in deciding to proceed; That, considering the circumstances of reduced visibility and what Captain Cota did and did not know about the ship and the conditions along his intended route, he failed to exercise sound judgment in deciding to get underway; That he failed to ensure that his plans for the transit and how to deal with the conditions of reduced visibility had been clearly communicated and discussed with the master; That, once underway, he proceeded at an unsafe speed for the conditions of visibility; That, when he began making his approach to the Bay Bridge, he noted further reduced visibility and then reportedly lost confidence with the ship’s radar. While he could have turned south to safe anchorage to await improved visibility or to determine what, if anything was wrong with the radar, he failed to exercise sound judgment and instead continued on the intended transit of the M/V Cosco Busan, relying solely on an electronic chart system with which he was unfamiliar; and that Captain Cota failed to utilize all available resources to determine his position before committing the ship to its transit under the Bay Bridge.

The board investigation did not have the authority to examine or comment on whether others on the bridge at the time shared responsibility. One of the most common elements in incidents to ships under pilotage is poor bridge resource management. The report comments: “As Captain Cota approached the Bay Bridge, visibility began to deteriorate. (he) still had the option of utilizing VTS to fix his position and/or abandon the transit and use the availability of Anchorage 8 or 9. In addition, he had the availability of crew members to fix the vessel’s position, and potentially the vessel’s lookouts to identify any structures. None of these resources were utilized. Instead, Captain Cota continued to rely exclusively on resources in which he had limited or no confidence.”

At the time of the incident the master of the Cosco Busan, Captain Sun, and his crew had been aboard the vessel for just two weeks.

In June this year Captain Cota surrendered his California state pilot licence and retired as of 1 October. Says the report: “It should also be noted that, as Captain Cota has turned in his state pilot license and retired, this matter did not go through a full evidentiary hearing before an administrative law judge. Accordingly, this report reflects only the findings and conclusions of the IRC without having afforded the pilot an opportunity to test the evidence relied upon by the IRC in an administrative hearing. Furthermore, because of ongoing litigation, many witnesses were inaccessible. Under the Board’s regulations, this report by the IRC is nevertheless required.”

Relevant information:

Commission Report

Not Being John Cota

Cosco Busan Trial, Testing The Waters?

Pilot Terror

Cosco Busan Detainees – Where are the T-Shirts?

Cosco Busan Pilot Claims The 5th

US Justice Department statement on Cosco Busan Pilot

Cosco Busan Pilot Charged With Misconduct

Pilotage related Podcasts:

The Case Of The Baffling Bays

The Case Of The Confused Pilot

Sep 302008
 

MAIB’s report on the grounding of the 78-metre general cargo vessel Sea Mithril on the River Trent in fog three times in 30 minutes while under pilotage is certainly worth the read. It deserves to be mandatory reading for officers, those who aspire to
be officers, and for pilots

Sea Mithril is equipped with azimuth propulsion controls by joysticks on the bridge console. About a month before the incident Torbulk, the ship manager, sent instructions to its fleet that masters should ensure that someone else handles the controls during during critical periods so that the master could move around and maintain a good command overview.

That instruction was ignored on Sea Mithril so the master had to operate the azimuth controls, without being able to see the radar, along the tricky Trent in fog, an undeniably critical situation.

Apart from not knowing that the instruction had been ignored because it didn’t follow-up, Torbulk did not give guidance as to who should be trained or how or to what level of competency.

It’s worth pointing out, as the MAIB report does, that a certificate of competency in conventional steering is pretty irrelevant when it comes to steering with azimuth propulsion, which is a different skill set, but there is no competency standard for such systems.

Then there is one of the all-time-favourites making a guest appearance – the passage plan. Over the past five years MAIB has investigated 40 incidents involving vessels of 100 gt to 3,000 gt in which poor passage planning was a causal factor. Here was another one.

Sea Mithril’s passage plan was a list of waypoints, courses and headings to steer. It wasn’t laid out on the chart used aboard, BA 109 Plan B, but, then, a passage plan is a lot more than plotting course lines. It includes bridge organisation, equipment and port entry prearations. The one aboard Sea Mithril appears to have been rudimentary, possibly because the master expected the pilot to do everything.

While we’re at it, let’s take as look at that chart. At a scale of 1:50,000 it’s the largest scale chart produced by the UK Hydrographic Office for Humber, Trent and Ouse but doesn’t include much detail on depth and so forth in the Trent. In part this is because given the fast-changing river it’s hard to keep up with changes.

A far better option is a chart produced by Associated British Ports Humber at 1:10,000, in the area of the grounding, for its pilots. Other than pilots and a few local boaties hardly anyone knows they exist because ABP Humber hasn’t done a very good job of telling anyone about them. Visiting ships, like Sea Mithril aren’t likely to know about them.

Naturally, the pilot aboard the Sea Mithril carried a copy of the ABP Humber chart, he even put it on the navigation console, but the master didn’t know because, as is depressingly often the case, the master-pilot exchange was inadequate. They did not compare the pilot’s intentions with the passage plan so there was no need to look at the chart, something that might have given the master a better appreciation of the circumstances and hazards.

It’s common for pilots on the Trent to take the helm themselves rather than use the ship’s helmsman. In part this is because it gives them greater control when negotiating the tight turns found on the Trent but also, more worrying, because of the low competency of the helmsmen provided. In many cases, even though a vessel has the required number of certificated seamen, there are no competent helmsmen on board.

On occasion, masters expect the pilot to take the helm so don’t provide the necessary personnel.

Another reason for pilots preferring to take the helm themselves is that it can be difficult to gauge the rate of turn of vessels fitted with azimuth propulsion units, or things like Becker rudders, which we’ve covered before. Pilots used to this type of equipment feel more comfortable controlling it themselves.

The pilot on the Sea Mithril didn’t have that experience which is why the master, the only person on the ship who could handle the azimuth propulsion was at the helm.

This is where another star of maritime accident causation appears – bridge team management, or rather lack of it. We’re now in 20 metre visibility navigating the twisty River Trent without a functioning bridge team. The pilot isn’t getting the support he needs from the ship’s officers and the master’s overloaded controlling the azimuth propulsion because he hasn’t distributed tasks.

A lookout warns that he can see lights of ships at berth apparently very close and everyone on the bridge gets alarmed but the pilot doesn’t know what they’re excited about because they’re speaking Russian and no-one thinks to tell him what’s going on. They’re so busy talking to each other that they don’t hear instructions from the pilot and the pilot doesn’t know what the master’s doing at the controls and because of the fog there are no visual clues to tip him off.

First the ship grounds at her stem as the master tried to avoid the ships at berth. Next the master puts her full ahead and to starboard, pocketing her towards the opposite bank. The pilot intervenes and asks for her to go to port but the vessel ran aground quite gently on the soft mud bottom.

As it happens, Sea Mithril was suitable for NAABSA berths. That is, berths where the vessel is Not Always Afloat But Safely Aground. With high tide 25 minutes away, the pilot felt the best thing to do was for her to stay where she was until she could float off. Instead, the master put her on full astern.

After a few minutes, just before high tide, she refloated and headed astern towards the other bank. The master applied full ahead, but the vessel still grounded, although briefly and was able to come alongside the wharf.

The result of all this was badly a damaged azimuth propulsion unit and costly repairs.

So, lots of lessons there to think over. Don’t be a stick in the mud, let’s have your comments.

MAIB report on the Sea Mithril grounding