Put together three bays as alike as walnuts in a shell game,
a tired pilot, and an obedient second officer
and the right turn could be the wrong turn.
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The Pilot and the Second Mate
We’ll call them George and Hari, not their real names but they were real people.
George was one of two pilots who boarded the bulk carrier Raven Arrow on September 23, 1997. He’d only got his pilotage licence in June that year but he knew the area well. He’d been trained in the US and France and had Bridge Resource Management Training, so George knew his stuff. It was a busy time of year for pilots and George was almost at the end of an 80 day work cycle.
Hari was second officer on the Raven Arrow. He’d been an officer for about eleven years, eight of them as second officer. He’d served on VLCCs, bulk carriers, and tankers. He had joined the vessel on September 17, seven days before the incident, and this was to be his first inside passage along the British Columbia coast.
Built in 1981 the 25,063 tonne Raven Arrow was a 183 metre length over all bulk carrier. She carried two radars with automatic radar plotting aids and two GPS receivers.
At 1300 on September 23, 1997, the Raven Arrow departed what was then the Pioneer Grain Terminal, North Vancouver Island for Kitimat, where she was to pick up a second load. Her course would take her along the North East Coast of Vancouver Island through the Johnstone Strait past Forward Bay, Boat Bay and Growler Cove to enter the Blackney Passage for Kitimat.
George was the first pilot on watch and conducted the vessel until 1800. Hari was the officer on watch.
Hari was alert enough to notice that the vessel was north of the charted course the Strait of Georgia. He asked for routing information from George who told him that they would be taking an alternative route to the one marked on the chart.
After his duty finished at 1800, George should have rested until 2300 when he was due to take over from the second pilot again but he was seen on the bridge. The second pilot noticed that he didn’t talk much and his head was lowered, typical signs of fatigue.
At midnight Hari again took over from the master as officer on watch. The master’s standing orders were ordinary enough: All Rules of the Road to be strictly observed. Do not hesitate to use whistle/engines/helm as and when required, the Pilot’s presence on the bridge does not relieve the OOW of his duties, the OOW should plot vessel’s position every 15 minutes, the OOW must, at all times, execute and monitor the passage plan, and call the master at any time the OOW is in doubt, or if visibility deteriorates to three miles or less.
George remarked on the similarity between the
intended course laid-off on the ship’s chart (purple)
and those he would normally take (red)
George and Hari chatted and George remarked on the similarity between the courses pre-plotted on the chart and those he would normally take in that area, but didn’t mention that the ship’s planned track into the Blackney marked on the chart didn’t match the course in the pilot’s book. George didn’t tell him because Hari didn’t ask.
Pilot’s intended track (red) compared to ship’s intend track (purple)
Two minutes after the change of watch, the pilot reported in to the Vancouver Marine Communications and Traffic Sevices, MCTS, that the Raven Arrow’s ETA at Boat Bay at 0135 and was warned of up-coming traffic.
It was night but visibility was good, the winds light and the sea calm with the current ebbing at 1 knot. George navigated by radar, consulted his personal course book for the necessary course changes and gave the necessary orders. Hari checked the GPS, plotted the vessel’s course on the chart and made absolutely sure that the helmsman obeyed the pilot’s orders.
Ahead of them traffic increased as fishing boats headed for home. At 0100 they began to encounter traffic and George concentrated on collision avoidance and made port-to-port passing arrangements with several fishing boats.
At 0113 George reported to the MCTS that he was off Boat Bay light. There was no MCTS radar coverage of the area so they had to rely on George’s report, but they might have wondered how the Raven Arrow, moving at just under 15 knots, made her position 17 minutes ahead of the ETA.
Hari wasn’t listening to George’s radio conversations, so he didn’t wonder either. In fact, what George had seen on the radar was Forward Bay, several miles to the east.
At 0115 Hari marked the last position on the chart at five and a half miles east of Boat Bay but didn’t tell George.
Visibility began to deteriorate and fell to around 150 metres. At times the masthead light was only just visible. Hari did not call the Master.
About 15 minutes later, Hari did ask George to confirm that the vessel’s ETA at Pine Island, a prominent position farther along the track, was 0800. George’s response was that he hoped that they han’t missed the alter course point. They both checked the radar and Hari asked whether they’d reached the alter course position and George said they had.
Hari took a range and bearing from the radar, jotted it on the chart. George glanced at the radar and saw what he thought was Baron Reef-Growler Cove and the opening he expected. With the ship four cables from shore, he ordered the helm to 320 to enter what he thought was the Blackney Passage, but he didn’t tell Hari that’s what he was doing. Hari didn’t plot the position on the chart, he concentrated on making sure that the helmsman obeyed orders.
Within yellow circle, 3/4 mile radius,
a simulation of what George
expected to see. (Click for animation)
Suddenly, the opening on the radar was no longer there. George said aloud “I can’t see the gap anymore, can you?” then ordered hard starboard but it was already too late.
At 0133 on the morning of September 24, The Raven Arrow drove onto rocks, severely damaging her hull Fortunately no-one was injured and there was no pollution.
George reported the grounding, giving his position as off Cracroft Point in the Blackney Passage. The master, alerted by the grounding, came to the bridge and replotted the position. The Raven Arrow had grounded in Boat Bay, six miles east of where he thought he was.
Right Turn, Wrong Bay
Fatigue messes up memory and judgement and George was fatigued and relied on his memory to make judgements.
He followed the headings and bearings in his course book, but didn’t note the course changes as he made them, he had to remember the last course and where he was, while at the same time handling the changes necessary to avoid fishing vessels. That’s why he missed a course change.
If he had been alert, he would have checked the ship’s position when he apparently arrived off Boat Bay seventeen minutes ahead of his ETA which would have required an unrealistic speed of 19 knots. It was a warning sign that something was wrong.
He could have refreshed his memory by looking at the chart or asking for verification from Hari, but he didn’t.
There were three bays along the coastline that, at a quick glance on the radar, looked very much alike: Forward Bay and Boat Bay, six miles apart, and Baron-Reef-Growler Cove, four miles west of Boat Boat Bay.
Forward Bay, Boat Bay, Baron Reef-Growler Cove as
they may have appeared approx head-up on radar
A key difference between Forward Bay and Boat Bay is that Boat Bay has a flashing red navigational light. George assumed that he couldn’t see the light because of the deteriorating visibility. It was another warning sign. He could have asked Hari for confirmation but didn’t.
He turned right at the wrong turn.
Once George realised he couldn’t possibly be in the Blackney Passage another effect took over. He had the choice of going 120 degrees to starboard or 60 degrees to port. He reacted as if he was in the Blackney passage, where the starboard turn would have given a better chance of avoiding the grounding. In fact a turn to port might have saved the situation.
His ‘mental model’ was that he was in the Blackney Passage. It was the wrong model.
It would have helped if George had asked Hari to assist in navigation, but he didn’t. During their first watch together Hari had shown that he had the necessary skills as a navigator to reduce George’s workload but pilots commonly like go it alone particularly when the officers on the bridge don’t have English as a first language. Hari’s first language was not English, but there was no communication problem.
At the same time, officers on the bridge are often only too happy to let the pilot do his thing, forgetting that the responsibility for safe navigation is always with the master or the master’s representative, the officer on watch.
Forgive me for repeating that: The responsibility for safe navigation is always with the master or the master’s representative, the officer on watch, not the pilot.
If the two of them had worked together, I wouldn’t be telling you this story now.
Hari, of course, should have alerted the master when visibility dropped to less than three miles, that was in standing orders and it would have made sense to have another set of brains in the bridge in bad visibility.
It’s worth noting, too, that George and Hari each only used one method for determining the ship’s position. That’s one bad navigational practice and like mice in the pantry, where there’s one there’s probably more.
So, when you’re on watch with a pilot on the bridge stay alert.
Go over the passage plan with him and make sure you know what he intends to do and when. If there’s a discrepancy, clarify it.
When he’s talking on the radio, listen and compare what he’s saying with what you think is happening. If Hari had done so he could have alerted George that they were at Forward Bay, not Boat Bay, when he reported his 01.13 position to the MCTS.
Of course, you’ll be regularly plotting the ship’s position, won’t you? Give that positional information to the pilot, confirm that’s where you should be. If Hari had told George their position, George wouldn’t have made that last turn into Boat Bay.
With two radars on the bridge, consider setting one to a longer range. On the Raven Arrow it would have given enough time for Hari or George to spot that they were in the wrong place.
Compare where George thought he was (right)
to where he actually was (Left).
Yellow circle simulates 3/4 mile radar range.
In any case, always monitor what the pilot is doing.
Working as a team means you can spread the workload and support each other. It also means you’ve got a better chance to trap errors and keep your ship afloat. No matter what safety systems are in place, the well-being of you, your crew and your vessel is down to you.
A personal suggestion that won’t go down well with some folk is to assume that the pilot is fatigued. He probably won’t be but it’ll help you stay on your toes. After all, it’s your career at stake.
This is Bob Couttie wishing you safe sailing.