Pilotage Paradox
by Paul Drouin
The Cosco Busan accident, as with many others that have the same root cause, can be categorized into what I call the pilotage paradox. For on the one hand, we wish to confide the safety and con of the vessel to the pilot, yet on the other insist it is the crew and captain that are ultimately responsible and accountable for the safe conduct of the vessel.
In the seven minute interval between leaving the inner harbour and striking the bridge pylon, the pilot gave 13 helm orders without the slightest indication on the bridge of the Cosco Busan that anything was amiss. We know this because the National Transportation Safety Board (NTSB) has left an amazing amount of information on their public docket website, including transcripts of the bridge voice recordings.
Leaving berth 56 (Port of Oakland) and passing under the San Francisco-Oakland Bay Bridge is a relatively simple matter, even under blind pilotage conditions, as only two course changes bring you through the span. The Delta-Echo span of the bridge is wide, with a horizontal clearance of 673 meters, and is equipped with a RACON dead center of the span. For the Cosco Busan, winds were light and the vessel would be stemming the flood current as it passed under the bridge. This maneuver should not give an experienced 3rd Mate cause to sweat, much less an experienced pilot.
Under keel clearance was not great for the Cosco Busan, however, and as a consequence hydrodynamic forces on the hull caused by the flood tide would have been strong as the vessel’s sidebody came to obstruct the flow, which was setting at approximately 130° (T) near the bridge and anywhere up to 168° (T) further from the bridge.
While it has subsequently come to light that a passage plan for the pilot assisted portion of the voyage did not exist, the outcome would have probably been the same had there been one. Why? By many accounts, pilotage is still a “one-man-show” in most parts of the world. The intended route is almost inevitably “in the pilot’s head” and a “team approach” is in theory only. Under this paradigm, if the pilot, for any reason, loses situational awareness or makes the wrong decision, the team cannot correct, object or challenge. I have found, in my ten years as an accident investigator, that while crews and pilots are generally well informed of BRM techniques, they do not apply them when a pilot has the con.
I am aware of only one pilotage jurisdiction that has radically changed the way they do business. For ships arriving off Brisbane, bridge teams, and in particular the OOW, can expect to be treated differently by the pilot – they can expect to be treated as an effective member of the navigation team. Brisbane pilots have, for some years, introduced the following procedures;
- On boarding, the pilot asks to see the ship’s passage plan and the pilot takes the bridge team through his own passage plan during which time any variances in the two plans are discussed and resolved.
- The pilot will not take over the con of the vessel until the courses on the ships charts and the pilot’s passage plan are the same. Any variances are amended on the ship’s charts (paper), ENC, and radar.
- The OOW is asked to confirm with the pilot each alter course position as they approach to within 7 cables of the position as well as the mark used to alter course and the next course.
- The bridge team is encouraged to use the pilot’s Portable Pilot Unit (PPU) for comparison purposes – but not as a prime means of monitoring the ships position. The PPU is used as an aid to navigation, independent of the ship’s equipment.
This last point is reassuring as we now see a proliferation of pilotage authorities adopting the use of PPUs by their pilots. While this is not in and of itself a bad thing, if the bridge team is excluded from this equipment we would only be entrenching and validating the “one-man-show” paradigm.
Brisbane pilots must be congratulated for breaking the mold and showing the way forward to a better way of pilotage. Yet, their innovation was not without some resistance. When first developed, a number of their pilots were convinced they could never get foreign crews to competently participate in such an exercise. These preconceptions have proven quite wrong! Today, some six years along, Brisbane pilots have been pleasantly surprised by the competency and cooperation of ship’s crews. And the corresponding response from crews has been one of enthusiasm and a sense of genuine participation in the pilotage operation.
Some jurisdictions, such as those with short pilotage runs (but not exclusively so), may try and rationalize away these procedures as not practicable for their area. But in today’s world of electronic charts, DGPS, centralized vessel traffic control, and easy electronic communication, these are only feeble excuses – a death clutch to the old way of doing things. For a majority of pilotage areas today, there is no reason why standardized pilotage passage plans cannot be transmitted to the vessel beforehand so as to be noted on the charts, electronic or otherwise. When the pilot boards the vessel, any last-minute corrections or changes can be agreed upon, thus proceeding without delay – and everyone is singing from the same song sheet!
In a published report by the Transportation Safety Board of Canada (TSB) one can review circumstances similar to that of the Cosco Busan. While downbound in the river at night and while under pilotage, the container vessel Horizon was allowed to continue past the pilot’s customary course alteration point (see “A” in diagram) by approximately three cables, or, in other words by 50 seconds at a speed of 15 knots.
Vessel Horizon positions before and after grounding (from TSB report M04L0092)
No correction or challenge by the OOW was forthcoming as the vessel passed the pilot’s customary course alteration point and plowed into the mud bank on the south side of the River.
Suffice it to say that bridge ergonomics, BRM, as well as pilotage practices and procedures have a ways to go before the precise navigation of a large vessel by a pilot and crew of two or more can be accomplished in a seamless, complementary and consistent manner. With the proper planning, intended courses can be adhered to and mistakes, if made, corrected in time to avoid nasty consequences.
Additionally, maybe vessel bridges will have to change –possibly reduced in size and with a more ergonomic and compact layout to bring the team together. Better all-round visibility would be a great advantage as well. Since BRM was inspired by the air industry’s “cockpit resource management”, maybe so too should the designers of ship’s bridges be inspired by the airplane cockpit.
TSB report M04L0092 – Grounding of the Container Vessel Horizon, 2004.
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This post submitted by Paul Drouin is a condensed version of an article written for the September 2008 edition of Seaways Magazine and can be found HERE.
Captain Paul Drouin is senior investigator with the Transportation Safety Board of Canada. He is a graduate of the Canadian Coast Guard College (class of 81) and a licensed Master Mariner (Unlimited). After serving for 15 years on all manner of Coast Guard vessels (five as master), Paul moved to a shore job as Marine Superintendant before beginning his investigator duties in 1998. He is also founder of SafeShip, a company dedicated to safer ships and safer crews. He lives in Lac-Beauport, Quebec with his wife and daughter.
Paul’s website: www.safeship.ca
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7 responses so far ↓
1 John Denham // Sep 18, 2008 at 11:38 pm
The pardox is concurred in however the explanation appears incomplete. The “root cause” is failure to comply with existing regulations, and an interpretation of who is directing the navigation of the vessel; an employed pilot not a ship’s officer or a ship’s officer licensed to pilot. (33CFR Part 164.11). Compulsory pilotage standards for duties and responsibility of “pilots in charge of a vessel” have been legally established in Atlee v N.W. Packet Co., (1874) ,88 U.S. 389, 22l.ed. 619.
By law, custom, tradition and attitude many pilots that have not experienced the courts continue to perform as “one man shows.” However one must recognize the difference between a river pilot and a bar/harbor pilot: e.g navigating the San Francisco Bar Channel and the ports on San Francisco Bay and the pilots that navigate to Sacramento and Stockton, California. Hearings, inquiries and investigation seldom develop the “root cause” of accidents because they have limited experience, knowledge and mostly are guided by bureaucratic constraints and therefore if fault is found, send the culprit to ship handling training. Why, because there is no other appropriate remedy available.
The statement that transiting the Oakland Bar Channel is a “relatively simple matter” is misleading in that the bar channel is nearly perpendicular to the currents and the published predictions are frequently inaccurate. Therefore, in limited visibility the person directing the navigation must rely on radar navigation to determine set and drift. Also, as one transits the bar channel the effect of the current changes. Experience in this case dictates: in fog, concentrate on radar navigation.
Regardless, no one knows what actually occurred except the Captain of COSCO BUSAN and pilot Cota i,e: why so many rudder orders? What passage plan was discussed? Was the track plotted on the chart 588 accepted by the pilot and Master? The NTSB hearing produced exceptional testimony and information however, no analysis or report has been produced, but professional mariners and second guessers have theories.
Under keel clearance does have a maneuvering effect in current and changing water depths, but not relevant in this case. Using only NTSB data at time 08 27 37 Cosco Busan has no feasible alternative course change to the right.
Most importantly, is the mostly common practice of pilots and ships not using BRM as a safety feature in voyages and navigation practice. The non-functional practice of BRM is concurred in. Although taught, stressed and published it is not universally followed; and now the cause is known!
Lastly as I recall, Brisbane Australia has a relatively calm and secured bay for pilot operations that allow discussion. Not so on at the sea boarding stations at some west coast pilot stations, however there is no rule that demand full speed till otherwise required.
Essentially, if the BRM is to be accepted and function then the professional pilots must be implementers. JGD
2 Paul // Sep 19, 2008 at 4:52 am
John,
I don't quite understand what you mean when you say, “Under keel clearance does have a maneuvering effect in current and changing water depths, but not relevant in this case. Using only NTSB data at time 08 27 37 Cosco Busan has no feasible alternative course change to the right.”
My point was, as the CB came to port (and then, of course, too much so), the tidal current would push on the ship with greater force (and hence send it off the intended course faster) with low UKC than if UKC had been greater. All of this contributing to the loss of situational awareness of the bridge team - i.e.”where are we now?”
3 Paul // Sep 19, 2008 at 4:59 am
Brisbane has found a way to include the OOW as a functional member of the team. As each pilotage area is different, their own solutions may also be different. However, they must all find a way to function as a team.
4 Kurt // Sep 19, 2008 at 8:43 am
Thanks for the article. I made a quick movie out of the radar images in the NTSB report…
http://schwehr.org/blog/archives/2008-09.html#e...
5 Cosco Busan Update | Bob Couttie's Maritime Accident Casebook // Sep 19, 2008 at 8:18 pm
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6 henningp // Sep 25, 2008 at 4:32 am
Fact is that most pilots do not care a sh… about the OOW but require Master to talk to.
Bad habit, but well, what to expect if masters still instruct their mates to be called before course changes (even for collision avoidance on high seas)…. and of course the mates do show themselves accordingly confident!
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