BRM Removed! Passage Exposed to Single-person Error Results in Near Grounding

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Summary

On 12 February 2017, the fully-laden bulk carrier, Aquadiva, was departing Newcastle Harbour under the conduct of a harbour pilot. At about 2218 Australian Eastern Daylight Time (AEDT), during Aquadiva’s passage through a section of the harbour channel known as The Horse Shoe, insufficient rudder was applied in time to effectively turn the ship. The ship slewed, or moved laterally (sideways), toward the southern edge of the channel, and at 2224 it was over the limits of the marked navigation channel. Additional tugs were required to arrest the ship’s movement and return it to the channel to complete its departure.

Findings

The ATSB found that bridge resource management (BRM) techniques were not effectively implemented throughout the pilotage. In particular, the harbour pilot’s passage plan was not provided to the ship’s crew prior to his boarding. As a result, the harbour pilot’s passage plan was different to that of the ship’s bridge crew’s. This meant they did not share the same mental model of the planned passage, and were unable to actively monitor the progress of the ship or the actions of the pilot.

As a consequence, the safety net usually provided by effective BRM was removed and the pilotage was exposed to single-person errors. Such errors, when they occurred, were not identified or corrected. When insufficient rudder was applied and the ship did not turn as expected, no-one from the ship’s bridge crew challenged or intervened to draw this error to the attention of the harbour pilot. Consequently, the ship travelled too close to shallow water.

The ATSB also found that ambiguities in the details of the incident (whether the ship touched bottom or not) and in reporting requirements, as understood by relevant responsible persons (as defined by the Transport Safety Investigation Regulations 2003) led to delays in the reporting of the incident to authorities, including the ATSB. These delays meant that evidence available at the time of the incident, such as voyage data recordings, were not collected.

Actions Taken

As a result of this incident, the Port Authority implemented a training and information process with pilots to discuss the incident and its outcomes and to inform them of their incident reporting obligations. Also, procedures are to be updated to require the use of portable pilotage units on all pilotages, and a project to implement sharing of electronic passages plans is also being undertaken.

Aquadiva’s operator provided targeted training to the ship’s officers. The company also completed an internal investigation and circulated the report and discussed and implemented identified preventive and corrective actions throughout its fleet.

Safety Message

Safe and efficient pilotage requires clear, unambiguous, effective communication and information exchange between all active participants. An agreed passage plan, its understanding and the establishment of a ‘shared mental model’ between a harbour pilot and a ship’s crew, forms the basis for a safe voyage. Without this, effective implementation of BRM techniques will be limited, removing the intended safety net provided by BRM and, in this instance, leaving the passage exposed to potential single-person errors.

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SourceATSB

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