An independent and confidential Issue 69

MARITIME FEEDBACK reporting system for the Maritime industry Autumn 2022

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Communication: the key to better safety Adam Parnell a port authority, but the good ports will always Director (Maritime) welcome constructive comments. If you witness anything you think could be improved, it should be raised with your DPA or mentioned to the pilot. This edition contains a wide range of different types Unfortunately, we also feature a report of a sub- of reports, and we are grateful to all our reporters for standard vessel. We are seeing more of these types of the high quality of their submissions. reports, which indicates there must be a large number One theme which links the majority of the reports of vessels sailing in a totally unacceptable condition. is the need for better communication at all levels, Such vessels tend to be quite old, so somehow they whether it is between ports and port users, between have traded for years without being detected by port vessels, or between the various parties on board a state or classification society surveyors. How is this ship. Our reports clearly demonstrate how a failure to possible? Are the inspectors spread too thin, or are communicate or a breakdown in communication can there surveyors who do not care or look the other so easily lead to misunderstandings and accidents. way? If you experience such vessels or cases where On a positive note, there is also a report where good deficiencies are not acted upon, please let us know. communication between the bridge team and the Until next time, stay safe! pilot prevented a potentially serious incident. The role of port authorities is a factor in One theme which links the majority some reports, and failures of coordination and communication again feature prominently. Many of the reports is the need for better mariners would probably be reluctant to criticise communication at all levels

Please note all reports received by CHIRP are accepted in good faith. Whilst every effort is made to ensure the accuracy of any editorials, analyses and comments that are published in FEEDBACK, please remember that CHIRP does not possess any executive authority.

Are you interested in becoming a CHIRP Maritime Ambassador? CHIRP and the Nautical Institute who also share your passion for to improve safety outcomes. The have an established ambassador safety, and you will quickly gain key attributes of a successful scheme to raise awareness of a broad knowledge of current ambassador is a passion for safety our incident reporting schemes safety issues. These are great and a willingness to speak up for and encourage the submission additions to your CV and increase CHIRP among your colleagues of incident, accident and your employability. and contacts. near-miss reports. Together we can promote the If this sounds like you, please contact As an ambassador you will join an development of a ‘just’ reporting us to discuss this opportunity at international network of seafarers culture across the maritime sector mail@chirp.co.uk

YOU REPORT IT WE HELP SORT IT

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M2051 Pressure – The crew put themselves under self-imposed pressure to provide a pilot ladder at 7m despite knowing this

Failure to challenge would be less safe than the designated embarkation point.

authority leads to a M2048

dangerous occurrence Initial report Bridge Resource A pilot boarded a tanker at anchor. When they arrived at the top of the ladder, they discovered that it was tied to a Management - Issues rotten railing, there were no suitable hand-holds nearby, and there were many trip hazards on the deck near the concerning helm execution embarkation point. When the pilot raised this with the master, he was told Initial report that the ladder was not usually rigged in that position but A vessel was entering the harbour by day with a pilot on had instead been moved to accommodate the pilot station’s board. After settling on a course of 168°, the pilot asked for direction to rig a 7m ladder. This was higher than the 5m a new course of 170° to set up for a wide turn onto the next maximum height at the normal embarkation point, so the (160°) leg. ladder had been moved. The helm correctly repeated back the 170° course to the pilot, who then looked down at their portable pilot unit (PPU). When they looked up, they saw that the ship had started to swing to port. The master and OOW challenged the error just as the pilot realised what was happening, and the swing was quickly stopped. One possibility considered by the pilot was that the helm might have had the next (160°) course in mind, which was to port. Visually too, there was a shoal beacon fine on the starboard bow, and the helm might have intuitively turned to open the distance from that navigational hazard. The pilot put the incident down to being a human factor slip, which he felt reinforced the need to check the rudder indicator with all course changes.

CHIRP Comment The master should have challenged the pilot station’s request to move the ladder from its designated position on safety grounds. In many cultures, authority figures are not challenged, which might have been the case in this situation. However, the master and crew know their vessel best! If the request was made because of a high sea state or significant swell, CHIRP would question whether safe embarkation would have been possible in such conditions.

Factors relating to this report CHIRP Comment Communication – Vessels should challenge any direction The reporter (pilot) is commended for self-reporting, a sign that means a departure from authorised procedures, of a strong safety culture at that port. Similarly, the use of particularly where safety could be compromised. closed-loop communication by the pilot and helmsperson and the swift challenges by the master and OOW indicate a Situational awareness – Before any activity, particularly strong safety culture among the crew. one which deviates from normal procedures, a dynamic risk Closed-loop communications are a good protocol for all assessment is vital to ensure that the area is safe. Had this safety-critical communications. been undertaken effectively, the crew should have noticed Several environmental stressors can affect how that the ladder’s fixing point was unsuitable. the helmsperson responds to helm orders. Creating the right communications environment with clear, concise Culture – The poor state of maintenance indicates that the communications will help the helmsman interpret the vessel’s safety and maintenance culture was inadequate. It orders correctly. Providing advanced intentions of helm also suggests a lack of external inspections and audits at the action at critical points in pilotage assists the bridge team in organisational level. anticipating the pilot’s action. In this instance, the clearest

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order would have been “Starboard wheel, steer 170°.” Some pilots augment their spoken orders with non-verbal signals, such as raising an arm or pointing in the desired direction, to minimise the risk of confusion. This is a good practice that CHIRP encourages OOWs and other pilots to emulate.

Factors relating to this report Communications – Ensuring that the spoken message has been received and understood and that the desired outcome is implemented is crucial during navigation manoeuvres. Different pilots and different bridge teams will all do things slightly differently. Ensuring that there is closed- loop communication at all stages of pilotage for helm and engine orders creates consistency and will improve navigational safety.

Alerting – Keeping the bridge team informed of current and future intentions reduces the risk that others will anticipate or misinterpret orders. This is particularly useful in times of high or low workload.

Teamwork – The master and the OOW reacted swiftly to the error; this shows a commendably high level of teamwork. Pilots often have many jobs during the day that can result in them feeling tired and making the occasional CHIRP Comment slip, and it is at these moments that they need backup and The reporter initially contacted ISWAN with their concerns. support from the bridge team. When you are on the bridge Because of the obvious safety implications, and with the of your next ship, consider how well you work as a team and reporter’s consent, these were passed to CHIRP. Shortly after what you can do to improve bridge teamwork. Does your CHIRP received this report, the coastal state detained the bridge team ever conduct a post-arrival/departure debrief? vessel when it next docked, and the crew were repatriated. The photographs suggest that the vessel has not been compliant with minimum regulations for a considerable M2028 (submitted by ISWAN) time, yet this was not detected by any external audit. This is not an isolated case, and CHIRP regularly receives similar reports. The number of vessels with unseaworthy or poor Enforcement of safety conditions remains stubbornly high, despite numerous international and national regulations regarding minimum regulations – is it safety, environmental and welfare standards. Flag states are obliged to enforce standards, but international law has few adequate? consequences if a flag state fails to do so adequately. Capacity and resource limitations reduce the number of inspections a port state may conduct, so substandard Initial report vessels like this can operate for a considerable time A seafarer complained about awful working conditions before being identified and detained. Seafarers on board on board their ship. The accommodation was unhygienic, unseaworthy or non-compliant vessels are encouraged to food was insufficient, and the equipment was in disrepair: contact CHIRP, who will advocate on their behalf. the main engine and gearbox leaked oil, and the seafarer CHIRP remains the confidential, independent and impartial claimed that oil and garbage were frequently discharged voice of the mariner, whose safety remains our priority. overboard. The air conditioning was also broken. The reporter stated that the chief officer was Factors relating to this report blackmailing the crew by threatening that anyone who Alerting – The ship’s crew have been responsible for raising reported the poor conditions would be dismissed. this matter to ISWAN and CHIRP, which is commendable. Alerting by the internal and external audit process has failed.

Competency – The management company does not have the necessary skills or willingness to run a shipconforming to the ISM code. There appears to be a total lack of adherence to the requirements of the Code, which is the minimum standard that should be applied. The Recognised organisation and Flag for this company must do more to achieve the minimum standard.

Pressure (Commercial) – The threats by the Chief Officer suggest that commercial considerations have contributed

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to a culture where violations of environmental, welfare and that CHIRP has previously noted about ‘VHF-assisted safety standards are not just tolerated; they are expected. collisions,’ it might also have been prudent to alert the PDV of their presence. Capability Do Flag and Port State have the ability to enforce minimum standards strictly? According to records Factors relating to this report which have allowed the ship to keep operating in this Situational Awareness – The yacht’s crew displayed good condition, the flag state appears to have not carried out any situational awareness, which was lacking on board the quality control inspection. motor cruiser. All vessels must keep a proper lookout at sea – there are no exceptions.

M 2033 Alerting – When in doubt of another vessel’s intentions, five short blasts on the whistle and at night, the flashing of a white light is an effective way to get another vessel’s Collision between power- attention. The VHF can also alert them to your presence, but the message should be short, concise, and positive if used. driven vessel and yacht narrowly avoided M2070

Initial report Our reporter writes, “We were sailing in our yacht, with a flat Mooring launch crushed sea, light wind, and perfect visibility, making about 4 knots on a course of 132° degrees. A very large motorboat came against the side of a into view dead ahead several miles away and continued towards us on a reciprocal course. We observed this container vessel motorboat as it came closer, mainly because its bow pointed directly at us. Initial report As it came closer, it showed no sign of changing course, The port berthing officer was attending to a large container even though it was motoring and we were sailing. When it vessel’s berthing when he received a radio message from was just a few seconds away, we started our engine and the mooring team to quickly head aft to investigate a serious made a 90-degree course change to starboard to avoid incident during mooring operations. being run down by it. We do not doubt that, had we not The aft mooring launch sat at the stern of the started our engine and turned out of its way, it would have containership, waiting for the third line to be lowered to run us down. them. Instead, the two lines that had been run ashore Our AIS receiver gave the vessel’s name and showed and were fast on the bollards were slackened off by a speed of 12.9 knots. The motor cruiser is a 50-meter- the aft mooring team and dumped into the water. The long vessel. We called the vessel on VHF Channel 16 and launch tried to move away from the lines to avoid getting immediately received a response. We said, ‘we are the yacht tangled. When the launch was almost clear, the ship off your stern that has just had to alter course to avoid being heaved up on the two lines again, only to catch the run down by you. The radio operator on the motor cruiser mooring launch, lifting it out of the water and crushing it said three times that they had not seen us and seemed to against the underside of the ship’s flare. The two launch be completely unaware of our presence or that they had crew considered abandoning the craft, as the prolonged nearly run us down.” shouting and blast of their horn did not succeed in getting the crew’s attention. Finally, the ship’s after mooring CHIRP Comment crew realised what had happened and slackened off the The power-driven vessel (PDV) should have maintained a lines. Other than the boat crew being severely shaken by proper lookout to “Make a full appraisal of the situation and the incident, there were no injuries to the crew but some the risk of collision” and then taken action under rule 18 to damage to the mooring boat. “keep out of the way of” the yacht. The yacht avoided a collision by her manoeuvre alone (rule 17). However, the CHIRP Comment moment it started its engine, it became a PDV; thus, this This is an obvious case of miscommunication during a manoeuvre was required under rule 14 (head-on situations). critical phase of the mooring operation. Both vessels had an obligation under rule 2 to ‘comply Vessels often pay out lines to take the weight off them with the ordinary practice of seamen’, which, in layman’s before transferring them to the working drums. The safest terms, means always using common sense. Although the method is to do this only after all lines are ashore, then yacht was strictly correct in maintaining her course and move one at a time to keep the lines and the vessel under speed, CHIRP suggests that an early and bold alteration to control. CHIRP wonders if there was a real - or perceived - starboard to stop a close-quarters situation developing could time pressure on the mooring party for them to take such a have been an equally valid course of action since both vessels dangerous shortcut. have a responsibility (again under rule 2) to avoid a collision. The yacht might also have considered sounding five Factors relating to this report short blasts (rule 34d) to indicate that it did not understand Situational Awareness – While launches or other vessels, the intentions of the PDV. And notwithstanding the risks such as tugs, often make line handling easier, it complicates

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the mooring officer’s task because that officer must With the above avoidance measures well underway simultaneously be aware of what is happening on board and and having the desired effect, I communicated with the over the side. A vessel rarely has enough crew to dedicate cruise vessel to establish which general direction they one person to each of these tasks, although that would be intended to take upon clearing the harbour to allow me to ideal. Instead, additional care must be taken when working plan the rest of my manoeuvre and not result in additional lines with vessels nearby. unnecessary risk. With them advising a course to the east initially before turning to the north, I elected to complete a Pressure – Mooring operations must never be rushed. full 360, allowing time and space for the cruise ship to exit Care is required by the master and pilot to provide timely the immediate harbour area and for me to generally pick up messaging to the mooring teams to ensure that each order the standard approach to our berth for arrival. is carried out carefully and unhurriedly. The main hazards were the proximity of the lee shore, with easterly winds, something that is factored into the Distractions – The mooring team were distracted when passage plan to allow extra room, including the shoaling they failed to hear the mooring boat crew’s signals when waters to the south of the berth; this knowledge allowed me they were trapped against the ship’s hull. Keeping alert to decide on early, positive and bold avoidance measures during mooring operations is vital, given the changing quickly, rather than allowing the risk to increase by nature of the ship’s movement and the strain on