The Case Of The Confused Pilot


If you don’t talk to your pilot you could be
heading for a bad turn


Listen To The Podcast



More than 50 maritime incidents each year happen with a pilot on board, costing and average of $850,000, grounding incidents like this one average almost $8m each.

We’ll call them Victor and Jun, not their real names but they were real people. Like the rest of the crew, they were Filipino. Their English was very good and that was the working language of their ship, the Stolt Tern, a product tanker of a little more than 3,200 gross tonnes.

Stolt Tern In December 2004, Victor was the ship’s master. He had plenty of experience. He’d been at sea since 1968, qualified as a master in 1983 and joined the Stolt Tern on 14 October, 2004 and assumed command a month later, two weeks before this incident. Now he was about to enter the port of Holyhead, Wales, for the first time.

Jun joined the company as a cadet in 1997. In March 2004 he boarded the Stolt Tern as third officer.

On the morning of 1st December 2004, The Stolt Tern was heading east towards Holyhead with the wind southeast force 1 to 2 and calm seas, Victor took over the watch from Jun and started the bow thruster as the pilot boat approached.Holyhead breakwater

The second officer had prepared the passage plan without tidal information because there hadn’t been tide tables on the ship since the beginning of the year, but none of its three masters during that time had reported this to the fleet manager, and the chart itself was not up to date.

Tidal information in the Admiralty sailing directions were based on a 1976 Royal Navy survey, revised in late 2001 using data provided by the port, but it didn’t update the tidal information which was misleading with regard to the area around the breakwater to the south of the port.

The pilot, we’ll call him Len, boarded at 0925.

Len was 65. He’d been raised in Holyhead and became principle pilot for the port in 1999. He probably knew those waters better than he knew his own bathtub and was well respected for his ship handling skills.

Becker Rudder

Len knew the Stolt Tern, he’d conducted her into Holyhead before, as well as her three sister ships, so, among other things, he knew she had a right-handed controlled pitch propeller, in fact she was very right right handed, 450 BHP bow thrusters and a Becker Rudder, a flap rudder which augments the turning ability of the rudder.

A switch on the bridge limited the rudder to 45 degrees when activated.

During 2004 there had been two incidents in Rotterdam involving Stolt ships with Becker rudders, both of them had a pilot aboard and, in both cases, there had been a reduction in speed and the limit switch on the Becker rudder had been over-ridden. Following these incidents the company revised its bridge procedures guide and pilot card – limit switches were always to be in operation at speeds of more then three knots, and only over-ridden when berthing. The pilot card advised reducing speed gradually and not to reduce speed when changing heading.


There was a master/pilot exchange and Victor told Len about not reducing speed while changing heading. Len gave Victor the intended route to the terminal, the intended berth and advised him to alter course to starboard to 140 which put the Holyhead breakwater light fine on the starboard bow, and to increase speed to full ahead. Manual steering was selected.

The port passage plan that Len handed over did not show the routes to the intended berth and there was no discussion about how far the vessel should keep away from the breakwater.

Len expected the ship to be set to the East by a tidal stream of up to three knots as she approached the harbour entrance which would cause her to pass within 1.5 and 2 cables of the end of the breakwater. He expected the ship to experience a brief turning moment that would swing her to starboard and he wanted to ensure that she was on a steady course aimed at a prominent chimney.

There wasn’t a helmsman so Jun took the wheel. When he needed to plot fixes on the paper chart, Victor replaced him at the helm. Otherwise, Victor operated the bow thruster, Jun was on the wheel and Len stood in front of the console watching the position of a chimney on shore. He could see repeaters for rudder angle and propeller pitch but couldn’t see exactly what Victor was doing.

The Bridge Of The Stolt Tern After around five minutes Len called for half ahead. When the ship was around five cables from the breakwater Len called for slow ahead.

At 0937 Len called for Starboard 10 to line up the Stolt Tern with the chimney. Jun put the helm to starboard five, equivalent to 15 degrees of conventional rudder and Victor gave a burst on the bow thruster and reduced speed to dead slow ahead, believing that was what Len had called for.

As the bow nosed beyond the breakwater at 0939, where the effect of the tide was less, the ship developed a sheer to starboard. Len ordered midships, then steady. Jun put on 20 degrees of helm.

Len called hard a port, Jun put the helm over to 35 degrees and Victor put the bow thruster to port but she continued to swing to starboard, and the breakwater.

Len called ‘stop engines’ then “full astern”. In Tagalog, Jun warned Victor that doing so would accelerate the swing towards the breakwater so Victor overrode Len’s advise, put the engines to half ahead, took the limiter off the Becker rudder and increased the port helm to 65 degrees.

By now there wasn’t enough distance between the ship and the breakwater for Victor’s action to be successful.

At 0940, three minutes after the turn began, the ship hit the bottom south of the Eastern end of the breakwater at around 4 knots, tearing a 2.3 metre by half metre gash just forward of the bow thruster and putting several dents in the hull.

Victor was so shaken that he forgot to sound the general alarm.

hhchartsm.jpgA Smack On The BTM

Would the Stolt Tern have grounded if Victor had followed Len’s advice to stop engines and go astern? We don’t know, but we do know what led to the incident: Poor bridge team management.

Len didn’t know what Victor was doing at the console with the bow thruster and the engine telegraph because Victor did not tell him. There may have been a misunderstanding, or Victor did what he thought best without telling Len.

On the other hand, Len navigated only by eye, he didn’t ask for ranges by radar or speed over ground, which Victor and Len could have given him. He didn’t ask and they didn’t tell.

Shortly before the grounding Victor and Jun spoke in Tagalog, Len didn’t know what they were saying so he didn’t know what they were saying.

If Len, Victor and Jun communicated with each other then they may well have recognised that something was wrong early enough to avoid the grounding.

stolt-tern-aground.jpgLen had piloted ships like the Stolt Tern many times along the intended route without incident, it was custom and practice, but the clearance between the ship and the breakwater didn’t give enough sea room to recover had there been a mechanical failure or if the ship had to take avoiding action, for instance, if a small craft had unexpectedly emerged from the small craft channel south of the breakwater.

So, how do you avoid running out of water with a pilot aboard?

Dodging The Dirt

One, man the bridge properly.

With a complement of 13, the Stolt Tern had two more crew than required by the Safe Manning Document A fully manned bridge could have helped. If there had been a helmsman on the bridge, Len would have known who was doing what and Victor and Jun would have been able to put greater focus on safe navigation and provide Len with the information he should have had.

Two, make sure there’s a real bridge team briefing.

A bridge team briefing was not only required by the company procedures, it simply makes good sense. When Len came aboard, a bridge team briefing would have ensured that each member of the bridge knew what the intentions were, what was going to happen and when. They have been properly prepared and problems might have been identified earlier.

Three, four and five: Communicate, communicate, communicate.

Take the initiative to keep the pilot updated on course, speed, position and other critical information even if he doesn’t ask for them. Confirm the advice he gives you and tell him what you’re doing. If a decision is made that’s contrary to his advice, make sure he knows about it.

When things start going wrong, the relationship between you and the pilot is critically important to the welfare of your ship and possibly your career.

If you’d like to comment on this or any other Maritime Accident Casebook episode send an email to or leave a post at our website at

This is Bob Couttie wishing you safe sailing.

(If you’re interest in pilotage related issued you may also like to hear The Case Of The Baffling Bays)

Official MAIB Report

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

You’ll need Quicktime for the following

Take a closer look at a Becker Rudder

How it works
How it affects water flow

  3 Responses to “The Case Of The Confused Pilot”

  1. Being ex Pilot myself – I may Say your title is wrong – case of confused pilot –

    I may call conflict between master and pilot
    Although your investigation is right.

    Basically approach is wrong, Pilot must line up with channel before entering breakwater
    So there is no stbd turn.

    My question – if master had followed pilots order what would have been chances of not hitting the break water ?//

  2. Many thanks for your comment.

    The ‘Confused’ part is because the pilot wasn’t aware of what the master was doing because he couldn’t see the console and didn’t understand what they were talking about at a critical stage, a prett confusing situation.

    This case was one of several proposed for the American P&I Club video series “Stranger on the Bridge”, which you’ll find at and, but didn’tr make the final three. Another one was The Case Of The Baffling Bays, which you might check out. In part they were a response to concerns raised by a report by the International Group of P&I Clubs (

    With regard to who was ‘right’, the official report itself says that’s it’s difficult to tell, however in other cases, liker The Case Of The Cygnet’s Kiss and The Quatsino Sound segment in Stranger On The Bridge, where Master’s have over-ridden pilot’s advice it’s happened too late to have much effect on the outcome.

    I would argue that the question is irrelevant. If the turn had been properly planned in advance so that each member of the bridge team knew what should be happening and when, and if they had communicated as a team, then the incident wouldn’t have happened.

  3. I know it’s too late to write any comments! Already 4 years passed!
    I have been sailing as captain on vessels aquiped with becker rudders.
    The approach was done correctly by the pilot.
    In this incident the person to blame is the Captain. He didn’t use the becker rudder to his advantage.
    Normally he should keep the same engine RPM when turning, the vessel is loosing her speed, make steady the vessel in the middle of the channel. Than he can reduce the RPM before the vessel was gathering.

    Of course, if you reduce the engine RPM during the turn, than the rudder effects will be drastically reduced.