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    Gard AS - Case Study - Pilotage

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    Naing Win Tun
    The document describes a case study of an incident where a tanker hit the berth while docking. Key factors that contributed to the incident included the pilot boarding closer to the berth than planned, the ship proceeding at an excessive speed, lack of communication and risk assessment by the bridge team, and distractions to the pilot from phone calls. Lessons include the importance of pilot/master information exchange, risk assessment, non-excessive speeds, clear roles and responsibilities on the bridge, and restrictions on phone use by pilots.

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    Gard AS - Case Study - Pilotage

    Uploaded by

    Naing Win Tun
    21 views2 pages
    The document describes a case study of an incident where a tanker hit the berth while docking. Key factors that contributed to the incident included the pilot boarding closer to the berth than planned, the ship proceeding at an excessive speed, lack of communication and risk assessment by the bridge team, and distractions to the pilot from phone calls. Lessons include the importance of pilot/master information exchange, risk assessment, non-excessive speeds, clear roles and responsibilities on the bridge, and restrictions on phone use by pilots.

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    The document describes a case study of an incident where a tanker hit the berth while docking. Key factors that contributed to the incident included the pilot boarding closer to the berth than planned, the ship proceeding at an excessive speed, lack of communication and risk assessment by the bridge team, and distractions to the pilot from phone calls. Lessons include the importance of pilot/master information exchange, risk assessment, non-excessive speeds, clear roles and responsibilities on the bridge, and restrictions on phone use by pilots.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    21 views2 pages

    Gard AS - Case Study - Pilotage

    Uploaded by

    Naing Win Tun
    The document describes a case study of an incident where a tanker hit the berth while docking. Key factors that contributed to the incident included the pilot boarding closer to the berth than planned, the ship proceeding at an excessive speed, lack of communication and risk assessment by the bridge team, and distractions to the pilot from phone calls. Lessons include the importance of pilot/master information exchange, risk assessment, non-excessive speeds, clear roles and responsibilities on the bridge, and restrictions on phone use by pilots.

    Copyright:

    © All Rights Reserved
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    of 2

    Case study for onboard safety meeting

    Pilotage
    Please read the below story of an incident. Keep our company’s standards and procedures
    in mind while reading to compare with the actions of the crew below as we will discuss the
    factors which led to the incident occurring.

    “Good afternoon, Capt. I’ll take over. Starboard 10, come to two five six degrees and full ahead.”

    We are on board a tanker, approaching a terminal somewhere in the Western Hemisphere. The speed is
    slowly increasing and the last light of day is rapidly disappearing. The pilot has just boarded the ship; one
    nautical mile closer to the breakwater entrance than the chartered boarding point. The atmosphere on the
    bridge is relaxed.

    “Full speed, Mr Pilot, 14 knots.” “Full speed. Thank you, Capt.” The pilot and the master continue to talk
    about everyday matters such as the weather, how long they are staying at the berth, etc. “I’m leaving the
    bridge”, says the master. “I have to prepare some papers before we berth. The second mate will assist
    you. Here is the pilotcard. If you need me, just tell him and he will fetch me.”

    The ship is still at full speed. The pilot calls the harbour master in his native language and tells him that
    ETA will be in 30 minutes. He also gives the three tugs waiting to assist berthing the ship an update on
    the situation (also in his native language). There is no request for translation from the second mate and the
    pilot does not share any information in English.

    The ship continues at full ahead. Traffic increases as the ship enters sheltered waters. The background
    lights from the harbour area make it difficult to see the difference between moving and stationary objects.

    “Mr Mate, can you prepare to receive the first tug on port bow? We will have starboard side alongside.”
    (Two other tugs are also ordered but this is not mentioned by the pilot). “Yes, sir”, says the mate. The pilot
    contacts the tugs on the VHF again (still in the local language) and, as he is talking, his mobile phone rings.
    The mate calls the master, who enters the bridge after a couple of minutes.

    The Master consults the radar and although it is many years since the last time he was in this harbour,
    he feels somewhat uneasy with our present speed, as we are rapidly approaching the inner part of the
    harbour. The master is tempted to ask the pilot to reduce the speed, but for some reason he does not. The
    pilot orders half ahead and continues to talk in his mobile phone. We are approaching the berth and the
    master is more and more anxious about the speed, so he politely suggests the pilot to reduce the speed.
    The pilot explains that there is another ship waiting to leave the berth and he has to board it as soon as
    possible.

    The first tug is closing in on port bow and is ready to receive the heaving line from the ship. The second
    mate, who has just left the bridge, is now on the forecastle making his first attempt at the heaving line,
    but misses the tug. He sees that they are now alarmingly close to the berth and hurries to do his second
    attempt. This time he succeeds and reports back to the bridge that the line from the tug is on board and
    secured. At the same time the pilot, who has just finished his telephone call, hectically instructing the tugs
    on how to berth the ship, still in the local language – this time with a raised voice.

    The tugs seem to have problems keeping up with the speed of the ship and this is communicated to the
    pilot. The distance to the berth is rapidly decreasing and the pilot asks for slow astern. The master, who is
    now becoming very nervous, orders slow astern and even increases this to half astern. The pilot orders the
    aft tug to start pulling in order to reduce the speed of the ship. The master finally realises that there is no
    way he can avoid hitting the berth and orders full astern. The ship hits the berth with a speed of 2 knots,
    making a 3 metre long gash on the starboard bow and causing extensive damage to the berth.

    If you have any questions or comments please contact Gard’s Loss Prevention team at lp@gard.no
    How to improve by lessons learnt
    Based on the case and the keywords, you should now perform an onboard risk assessment of the incident and the
    factors which led to it. Bear in mind our vessel’s procedures.

    You can also discuss the keywords below in order to determine onboard areas/topics for increased awareness:
    - Content of a proper Master – Pilot exchange of information. Is it only handing over the pilot card?
    - Risk assessment and pilot boarding point, how does the risk change when pilot boards closer to berth
    - Excessive speed –The importance of identifying the point-of-no-return in the planning
    - When do you question or intervene when procedures are not followed?
    - Roles and responsibilities when pilot is onboard. Who is the leader of the bridge team? Who is in command?
    - Communication and language challenges, when do we ask the pilot to translate?
    - Company policy – when is the use of mobile telephones appropriate or prohibited. Could we tell the pilot about
    this policy?

    1 What factors contributed to the incident in the above case?

    2 Risk Assessment: Could some of the factors identified be present on board your ship?
    (How frequent could they be present? How severe could it be if they are present?)

    3 In the risk transfer zone (yellow and red), what would you suggest as measures to control the
    risk? Any additional barriers that could be introduced?

    © Gard AS, July 2015

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