Tug Did Not Respond To Distress Calls – Phil. Duck Report

 Accident, Accident report, accident reporting, collision, Sinking  Comments Off on Tug Did Not Respond To Distress Calls – Phil. Duck Report
Sep 102010

A Ride the Duck DUKW in Seattle, similar to the amphibious vessel which sank in the Delaware

Distress calls and warnings by the master of the Ride the Duck DUKW that his vessel was disabled were not responded to by the tug Caribbean Sea which was handling a barge which collided with the DUKW and sank it, says a preliminary report from the US National Transportation Safety Board.

Says the accident report: “On Wednesday, July 7, 2010, the empty 250-foot-long sludge barge The Resource, being towed alongside the 78.9-foot-long towing vessel M/V Caribbean Sea, allided with the anchored 33-foot amphibious small passenger vessel DUKW 34 in the Delaware River near Philadelphia, Pennsylvania. The DUKW 34, operated by Ride the Ducks, carried 35 passengers and 2 crewmembers. On board the Caribbean Sea were 5 crewmembers. As a result of the allision, the DUKW 34 sank in about 55 feet of water. Two passengers were fatally injured, and 10 passengers suffered minor injuries. No one on the Caribbean Sea was injured.

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Pilots and the Loaded Gun

 pilot, pilotage  Comments Off on Pilots and the Loaded Gun
Aug 072009

Our friends over at Maritime Executive have a well-stuffed mailbag following a thoughtful article by Joe Keefe, “Game Changer: Reflecting Back on the COSCO BUSAN Debacle”, which had MAC mulling over Texas Chicken, Suez pilots and courtesans.

Says MarEx editor Joe Keefe: “ (The article) was, far and away, the most widely opened article in this e-newsletter in more than two years. Not surprisingly, the article also triggered a flood of mail in similar volumes.”

MAC was reminded of a complaint by a pilot about the IDESSIT/American Club produced series of pilotage videos Stranger on the Bridge which strongly recommends that a master monitor the pilot. The complainant said, dismissively “What? is the master supposed to jump on the pilot when he makes a mistake?”

The answer is “Yes, absolutely”. One MarEx correspondent quotes a New Zealand Pilot Card: “‘I am just the pilot & am here in an advisory capacity. Please feel free to bring any error of judgment, helm or engine order, to my notice’”, so MAC, and the great majority of masters he’s spoken with aren’t alone.

In fact, if being conducted by a Pascagoula pilot it is vital to monitor because, under the term of the Pascoula Bar Pilot’s contract with vessels the master and shipowner accept full liability for any damage caused by a pilot’s error, the pilot bears no liability, which of course means he, or she, bears no responsibility.

The essence of responsibility is liability, hence MAC’s reminder of the courtesan’s privilege – influence without responsibility.

Pilot and master do not, therefore share responsibility because they do not share liability.

A letter from another good friend of MAC’s, Pilot Mag editor John Clandillon-Baker says: “In the Zim Mexico III case in 2006, Captain Schroeder was found guilty because ‘the judge also instructed the jury, in essence, that the captain of a vessel, under the applicable Code of Federal Regulations provisions, is responsible for the negligence of all his subordinates on the vessel, including the pilot’. The Cosco Busan case has overturned that and confirmed a growing opinion that a pilot cannot walk away from an incident with immunity if his actions are deemed to have contributed to the incident.”

Newspaper editors and ships’ masters share a common legal oddity. In most jurisdictions a company employee is not personally liable and cannot be sued for the outcome of their decisions. Masters and editors are personally liable for the outcome of their decisions and the decisions made by their subordinates. The essence of the Pascagoula Bar Pilots is that the pilot is not an independent professional but a servant of the company which contracts him for his professional services. As such, he is subservient to the master of the vessel and the master much accept responsibility for the expertise of a pilot whom he may not know in waters he doesn’t know and if anything goes wrong the master pays.

This would appear to conflict with the best practices advice of the American Pilots Association, APA, which states that a pilot is not part of the bridge team because: “State-licensed pilots are expected to act in the public interest and to maintain a
professional judgment that is independent of any desires that do not comport with the needs of maritime safety. In addition, licensing and regulatory authorities, state and federal, require compulsory pilots to take all reasonable actions to prevent ships under their navigational direction from engaging in unsafe operations.”

Therefore, in the APA’s view, a bridge team’s duties conflict with maritime safety. It is also implicit in that statement that the pilot is not a subordinate of the master.

Although the APA states “If the role of the pilot is an unclear issue, it is only because some people want it to be unclear or confused” it does nothing to clarify the issue in its best practices.

APA seems not to understand the concept of a bridge team. Anyone on the bridge participating in, and with the objective of, safe navigation of the vessel is a de facto member of the bridge team because safe navigation is the objective of the bridge team.

Also implicitit the APA best practices is that the pilot only need tell the master what he thinks the master should know, not what the master wants to know. The pilot is not required to tell the master his intentions until and unless he choses to do so.

Repeatedly pilots’ organisation state that a master may dismiss a pilot and ask for another one if a pilot is deemed to be incompetent or incapable of carrying out his duties. In the case of Cosco Busan, and several others, a pilot’s fatigue or the influence of medication, has not been readily apparent. A master also has the right to dismiss a pilot if the vessel is put into a situation of extreme danger. This latter point might have been workable in the age of sail when 5 knots was good speed but given modern speeds by the time a vessel is in danger it’s too late to fire the pilot and, indeed, may make matters worse.

Not a single American pilot organisation has suggested at which point the master of the Cosco Busan should have dismissed John Cota as pilot. When they identify that moment is when they should stick their heads above the parapet, yet they place the blame on the master for the contact, allision, with the San Francisco-Oakland Bay Bridge.

A stroke of common sense comes from a legal analysis forwarded by the chairman of the UK Pilots Association, John Wilson.

To cut to the chase, a pilot is given a special privilege and licence to conduct his profession. With that privilege comes a duty and responsibility to the client and to society as a whole. As a professional, a pilot is liable for the errors he makes.

A pilot is, therefore,in the same position as a doctor. A doctor is only an advisor, the patient can chose to accept or dismiss the doctor’s advice, but if the patient chooses to accept it then the doctor is liable for any negative outcome.

Pilots are given special and exclusive privileges and are well paid for their services, in return they should be held liable for their professional advice in pursuit of those privileges. You expect the same of your dentist and optician.

Then there is the issue of intimidation. What counts as intimidation depends upon culture. One of MAC’s British clients tell the story of a Suez Canal pilot who spent the entire passage telling him that he, the pilot, could cause as much damage as he liked to the vessel or the canal infrastructure, and get away with it – the master and the shipping company would be held to blame in much the same way as in same in Pascagoula.

A MarEx correspondent tells this story: : “I have personally observed an Asian Master, who wouldn’t leave anything to chance with Asian Pilots when in Asian / Middle Eastern Ports, however was reluctant in pointing out the pilot’s minor errors during a river passage in the United States, where two pilots on the wheelhouse were going on chatting endlessly, discussing personal & social issues with an immensely complacent attitude towards the job they actually came for. In fact, most of their helm orders sounded so seamless with their personal conversation, that it was extremely difficult for the helmsman to figure out where the ‘PORT TWENTY’ was concealed between his wife’s shopping & his son’s new boat with the Yamaha outboard! It was indeed surprising to see a Ship’s Master with over 2 decades of command experience under his belt, act in that intimidating manner, putting the safety of his vessel & crew at risk. When asked for a clarification by me after berthing, his explanation was equally shocking! “We must be courteous & extend hospitality

to all Port Officials” was his answer.

The Chinese master of the Cosco Busan behaved in exactly the same way. The pilot,the American professional, gave his professional advice that it was safe to depart the berth at Oakland. The master accepted that advice in the same way a patient would accept the advice “take two asprin and call me in the morning”.

Which gets me to Texas Chicken, sometime called the Texas Two-step on the Houston ship canal. It is a scary procedure for a master and quite fun for the pilot. When two ships are to pass the pilots on each ship aim at each other’s bow and, at apparently the last moment give a starboard 20 order. Pressure from the bows keep the vessels apart but, as the pass go on, another order is given to avoid suction from the stern of the vessels. It’s an impressive manoeuvre. But…

But, as can be found on the internet, pilots tell of occasions when the master has asked ‘did you see that ship?’ and the pilot has mischievously said ‘what ship?’. Should the master now relieve the pilot? And at which point in that manoeuvre, since the pilot did not brief the master adequately, should the master have relieved the pilot?

Pilots need to be taught how to deal with other cultures in a non-intimidating way. If American pilots are going avoid responsibility for their actions then “I am just the pilot & am here in an advisory capacity. Please feel free to bring any error of judgment, helm or engine order, to my notice” should be given verbally and on every pilot’s card. None do so, and, indeed, the San Francisco Bar Pilots card makes it clear that the pilot is in charge.

American pilots should also learn to accept responsibility for their own actions. Until they are liable for those actions, and while they continue to make the master liable for the pilot’s incompetence or inability then no master should trust them.

Kition vs I-10: Once More Unto The Bridge…

 allision, collision  Comments Off on Kition vs I-10: Once More Unto The Bridge…
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.

Been There, Hit That – Communications Failures And A Clobbered Dolphin

 accident reporting, MAIB, maritime accidents  Comments Off on Been There, Hit That – Communications Failures And A Clobbered Dolphin
Oct 202008

About one in five maritime accidents involve communications failures and so it was when the product carrier Sichem Melbourne suffered damage and nearly collided with an oil tanker after making heavy contact with mooring structures at Coryton Oil Refinery Terminal with a pilot aboard on 25th February 2008.

It was not an untypical situation: An inadequate master pilot exchange both men had passage plans but did not compare them, both assumed that they knew what the other would do. The bridge team spoke Russian to each other and didn’t communicate with the pilot so he was out of the loop.

Investigator’s from the UK’s Maritime Accident Investigation Branch comment: “The pilot made a comment to the master that an hour of ebb tide remained and that, consequently, they should use the bow spring in letting go. The pilot did not fully explain how he intended to move the vessel clear of the jetty.

“The pilot, who was stationed on the port bridge wing with the master, gave instructions to come ahead on the forward springs with hard port rudder, with the intention of creating a “wedge” of water between the ship and jetty, before coming astern into the river and current.

“When an angle of about 7o had developed between the ship’s stern and the jetty, the master applied bow thrust to starboard to prevent her bow leaning against the jetty. Soon after this the bow spring was cast off before the pilot was ready, allowing the ship to move forward before the current. Combined effects of increased starboard bow thrust and wind on the starboard quarter caused the ship’s port quarter to fall back and scour the jetty before she cleared the structure. Once clear of the jetty the pilot attempted to retrieve his original plan of getting the stern outwards by applying port wheel and more ahead power. The master, however, was under the impression that the pilot was trying to lift the vessel bodily into the river, and applied more starboard thrust to assist. The following tidal stream prevented transverse lifting of the ship and she was carried down onto other mooring structures.”

Says the MAIB report on the incident: There was an unspoken assumption between the master and pilot that each knew what the other’s intentions were. They each had a plan in their mind for taking the ship off her berth, but did not adequately share it with each other… The master and pilot were standing next to each other on the bridge wing as the incident unfolded over a period of some 10 minutes, but during this time as the ship scraped and bumped her way towards MD41, neither made any attempt to explain what they were trying to achieve. ”

A similar accident occurred happened on 11 January 2008, some six weeks before the Sichem Melbourne incident. The products tanker, Pembroke Fisher, suffered damage to her propulsion and steering systems after making contact with Black Shelf buoy, while under pilotage. She, too, was head

down, during an ebb tide and under compulsory pilotage. The root cause of the accident was identified as a failure of the master and pilot to agree, in sufficient detail, the procedures for clearing the berth, with poor bridge teamwork and communications being a contributory factor. As a result of this accident Port of London Authority circulated “lessons learned” to its pilots via the Authority’s intranet system and by hard copy, but not in time to benefit or prevent the Sichem Melbourne accident.

Download the MAIB report here.

MAIB also issued a safety flyer about the incident, download here

Kneejerk Legislation and Cosco Busan bandwagonning

 Uncategorized  Comments Off on Kneejerk Legislation and Cosco Busan bandwagonning
Apr 182008

Dennis Bryant at Holland & Knight clearly shares our exasperation at bandwagonning politicians climbing aboard the Cosco Busan. Commenting on a bill introduced by that global maritime expert Senator Feinstein, he says ‘The bill provides, among other things, that during a condition of enhanced danger (which includes dangerously low visibility, whatever that is) the USCG Sector Commander “shall assume direct authority over all vessels within the area . . . to ensure the safe navigation of dangerous waterways.”This is a truly misguided approach that will result in more problems than it expects to solve. ‘

What one wonders is whether that sector commander will be subject to criminal charges, face imprisonment and lose his career should an incident occur on his watch? Will he face the same legal risks as the pilot and ship officers aboard the Cosco Busan. Will the Coast Guard be fined millions of dollars for any pollution that occurs as a result? After all, if he, or she, is to assume direct authority over a vessel then he or she should be liable, as should the Coast Guard, so it’s little surprise that the Coast Guard itself really doesn’t want that particular hot potato.

In fact, there was little the VTS could have done at the time of the Cosco Busan incident. Its obsolete equipment had a time-lag between a ship making a manouvre and that manouvre being seen on the VTS screen, The equipment was obsolete because politicians had voted down funds for its upgrading.

Even modern equipment is not ‘real time’, there is always a lag which can be significant when dealing with fast-moving vessels.

VTS is not air traffic control. Every craft in the air is subject to air traffic control but the waters are filled with small vessels with little or no radar signature, without AIS, without radios, which can, and do interfere with safe navigation but will not be seen by the VTS.

Dangerous situations can arise without warning. At that moment, those on the bridge must remain focussed and undistracted, which they can’t be if they required to take orders from someone who isn’t on the bridge and doesn’t know the immediate situation. What will ensure will be a negotiation that will interfere with the bridge team’s situational awareness, particularly if the Coast Guard officer behaves with the typical abrasiveness of the breed.

One must, however, beware of the same sort of knee-jerk reaction that is influencing Feinstein’s bid for maritime glory. One must question whether direct VTS control is necessary or advisable in waters with mandatory pilotage, otherwise, why have a pilot anyway? Again, the issue of liability has to be settled.

There may well be an argument for greater VTS control, particularly in areas of high traffic density, and given the decreasing experience of many ship’s officers today, but ill thought-out legislation isn’t the way to go.