pilotage – Maritime Accident Casebook

Claude A. Desgagnes: Decisions, Comms and Confusion

Accident, Accident Investigation, Accident report, contact, contact/allison, grounding, pilot, pilotage Comments Off

Dec 162014

TSB’s report on the contact and grounding incident involving the general cargo vessel Claude A. Desgagnes as it entered Iroquois Lock in the St. Lawrence Seaway, is a tale of sticky decisions, poor communications and whose-in-charge confusion. One lesson is that once you’ve made a decision, keep in constantly under review.

Here’s the short version:

As the vessel proceeded downriver, the master and pilot spoke, but did not develop a shared understanding of the manoeuvre to be used in the approach to the Iroquois Lock. While the pilot had explained his plan to dredge the anchor to the officer of the watch (OOW) earlier in the voyage, the details of the plan were not relayed to the master when he arrived on the bridge.
Continue reading »

Don’t Mess With The Magnets

Accident, pilot, safety alert, Safety Alerts, safety flash, slips/trips and falls Comments Off

Dec 142014

If it ain’t broke fixing it may break it is the message from the US Coast Guard in a safety alert regarding embarkation hull ladder magnets after a State Pilot fell suffered concussion as he was boarding a vessel using its pilot ladder. In this case the modified magnet arrangement disconnected, fell, and hit the pilot on the head.

It wasn’t the first such accident to be caused by a modified magnet arrangement. Other incidents with injuries have occurred on other vessels at several different ports, says the USCG. In each instance the hull magnets were modified prior to the accident. Moreover, in all cases, after restoring the hull magnets to their original design no further problems were experienced.
Continue reading »

Cap Blanche: GPS Puts Pilot In A Fog

Accident report, boxship, bridge team management, Canada, containership, GPS, grounding, maritime safety news, pilot, pilotage Comments Off

Nov 072014

Looking out of the window was not really an option for the pilot conducting the 28, 372 GRT containership Cap Blanche on the Fraser River, British Columbia, Canada, on 25 January this year. With fog reducing visibility to 150 metres he could not even see the bow of the 221.62 LOA vessel, but he did have his trusty portable pilotage unit, PPU, which he relied upon exclusively for navigation and connected it to the vessel’s AIS. But the AIS had a secret, one which put Cape Blanche on the silt at the river’s Steveston Bend.

The accident report from Canada’s Transport Safety Board brings to light a little known aspect of navigation by GPS yet one that might not have led to the grounding had the pilot not been essentially left to his own devices even when his actions conflicted with the vessel passage plan.

The PPU had a predictor function that projects the vessel’s future position by performing geometric calculations based on the vessel’s current rate of turn, position, heading, course over ground, COG, and speed over the ground, SOG. The COG and SOG are derived from GPS values that continuously fluctuate, even when the vessel maintains constant speed and course due to inherent errors and inaccuracies in the GPS. To stabilize these values, a GPS smooths these inputs to provides the user with a more stable COG and SOG.

One can often see the GPS fluctuations on a GPS-equipped tablet computer or smartphone.

Did Bank Cause Suez Crisis?

Accident, Accident Investigation, boxship, collision, contact, container accident, containership, maritime safety news, pilotage, Suez Canal Comments Off

Oct 062014

Much bandwidth has been expended on social media, including MAC’s Maritime Investigation group on LinkedIn, following the collision between the German-flagged Hapag-Lloyd Colombo Express and the Singapore-flagged Maersk Tanjong at the northern end of the Suez Canal on 29 September. Captured on a mobile phone, the incident caused serious disruption to canal operations, dunked several containers overboard, and put a 20 metre dent in the port side of Colombo Express.

No-one was hurt there was no environmental impact and both vessels were able to continue on to an anchorage to await recovery of the lost containers and investigators from the Suez Canal Authority.

Even at this early stage there may be lessons to be learned.

Morning Midas – Money for Old Rope

Accident Investigation, Accident report, AMSA, maritime safety news, pilot, Pollution, port Comments Off

Jul 292014

Morning Midas. Photo: Eukor Car Carriers Inc.

Overboard is not the place for discarded mooring lines as Lombard Corporate Finance Ltd., owner of the Eukor car carrier Morning Midas, discovered in an Australian courtroom. As Australia’s Maritime Safety Authority, AMSA. points out wandering mooring lines are a hazard to other vessels, which is how this case came to light.

The errant 30 to 25 metre line was discovered the hard way by the pilot

launch Wyuna III in the early hours ofAugust 1, 2012 near the pilot boarding station outside Port Phillip Heads when it became entangled in the propellers of the launch and stalled its engines.

An AMSA investigation found charts linking two GPS locations from the Morning Midas deck log book and the site of the collision of the Wyuna III with the mooring line. Morning Midas failed to report a danger to navigation posed by the mooring line.

Tundra Grounding: Watch The Pilot.

Accident, Accident report, bulk carrier, fatigue, grounding, maritime safety news, pilot, pilotage 1 Response »

Jul 082014

A man apart: Fatigue and both physical and cultural differences played key roles in the grounding of the bulker Tundra.

Take one fatigued pilot, add cultural power distance, loss of situational awareness, a dash of unimplemented Bridge Resource Management , inadequate master-pilot exchange and passage planning and there’s a very good change of something unpleasant happening. TSB Canada’s investigation report into grounding of the bulker Tundra off Sainte Anne-de-Sorel, Quebec, is an interesting collection of what-not-to-does.

Groundings in which pilots are involved are among the most expensive. A study by the International Group of P&I Clubs estimated that although groundings only account for 3 per cent of incidents resulting insurance claims of more than $100,000 they accounted for 35 per cent of the cost of claims at a cost of $7.85m for each incident. That compares with collisions, which accounted for 24 per cent of incidents and costs, and fixed and floating object claims which accounted for 64 per cent of incidents but 33 per cent of claims.

There’s money in them thar ills.

When the pilot boarded the Tundra he did not have up-to-date information regarding the buoys he intended to use for navigation. One buoy has been removed, which was not necessarily going to be problem since the next buoy had distinctly different characteristics than the missing device and the pilot would have recognised the situation and adjusted accordingly. He did not have a documented passage plan – his was in his laptop. Continue reading »

Queenland Pilotage – “Systemic Issues” Says ATSB

grounding, maritime safety news, pilot, pilotage Comments Off

Jan 032013

The grounding of Atlantic Blue sparked the investigation

An investigation into Queensland pilotage operations has revealed “systemic safety issues” says Australian Transport Safety Bureau, ATSB. Under coastal pilotage regulations, no organisation, including the pilotage provider companies, has been made clearly responsible and held accountable for managing the safety risks associated with pilotage operations. This has meant that responsibility for managing the most safety critical aspects of pilotage has rested with individual pilot contractors instead of an organisation that systematically manages safety risk.

The investigation also identified systemic safety issues surrounding pilot training, fatigue management, incident reporting, competency assessment and use of coastal vessel traffic services. Continue reading »

Arklow Raider, Elka Apollon/MSC Nederlander: Squat and Bank Twofer Under Pilotage

Accident, Accident report, collision, grounding, maritime safety news, pilot, pilotage 1 Response »

Dec 192012

Damage to Arklow Raider after grounding at entrance to River Boyne

Two recent reports over the past few months, one a grounding the other collision and both with vessels under pilot’s advice, serve as useful lessons regarding hydrodynamic effects and vessel safety even when an expert is aboard.

In the case of Arklow Raider, she grounded as she passed the bar at the mouth of the River Boyne, Eire.

The Marine Casualty Investigation Board report says: “As the vessel approached the river bar, its speed was reportedly reduced. The data from the port’s VTMS gave a speed over the ground of approximately 5.4
knots between the Green and Bull light marks. The speed was 5.1 knots as the vessel passed Aleria light. The speed then dropped to 4.9
knots. At 19:30 hrs. the course was 053°T at 4.3 knots.

“The predicted time of high water was 19:54 hrs., the grounding occurred 20 minutes before the predicted high water. At 19:34 hrs. the vessel would not respond to rudder commands. The Master used both engine and bow thruster in an attempt to resume the correct course. At 19:35 hrs. the vessel touched bottom, veered to port and ran aground”.

Grounding: BBC Steinhoeft – Pilot Error Was On The Cards

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Jul 192012

view taken from the steering stand position on the bridge. When viewing in line with the forward mast from this point, the left-hand arrow indicates the reference point ashore being viewed, whereas the right-hand arrow indicates the reference point ashore as it would be viewed if one stood on the centreline and took a line of sight with the forward mast.

Pilots cannot know everything about your vessel – lack of critical information on the pilot card, or provided in the master/pilot exchange can put the ship and its crew at risk, as Canada’s Transport Safety Board points out in its report on the grounding of the multipurpose cargo ship BBC Steinhoeft in the South Shore Canal of the St. Lawrence Seaway in March 2011.

Says the TSB report: ”

While Pilot No. 1 was aware of the possibility of a parallax error in navigation due to the offset position of the steering stand, he estimated that error to be about 0.5° and therefore did not compensate for this when giving his navigation orders to the helmsman. The investigation determined that this error was in fact 1.6°.

In navigational areas where tolerances are small, such as in this occurrence, accuracy is of the utmost importance. However, the determination of the parallax error induced by an offset bridge layout is not something that can be accomplished accurately without specific information. In this occurrence, Pilot No. 1 was not provided with such information, and therefore underestimated the extent of the parallax error.”

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