Capt. Masayuki Kobori

Loss Prevention and Ship Inspection Department

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This column features the article contributed by our Association to "Mariners' Digest Vol.76", published in January 2025 by the Japan Shipping Exchange, Inc.

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Highlights

• To prevent accidents during pilot conning, it is crucial to cultivate a strong onboard safety culture where strict adherence to the SMS is the norm.
• This involves clear roles and tasks, thorough MPX, and robust BRM. Regular training reinforces best practices and helps prevent deviations from becoming normalized. New crew members must adapt to this culture, with the master correcting any deviations.
• Ultimately, preventing the normalization of deviations is key to safe navigation.
  
  
  

1. Why do accidents occur as a result of placing over-reliance on pilots?
   
   

Many accidents during pilot conning are caused by over-reliance on the pilot.

I carried out interviews with masters after accidents in order to analyze the causes and execute investigation reports. I asked the masters, “Do you understand that the master is responsible for the navigation of the vessel and the pilot is just an adviser?” All masters said, “Yes”. Subsequently, I analyzed ECDIS / radar / wind force / wind direction and other records through VDR and captured the lessons learned.

There is a tip to avoid incidents during pilot conning. It is “Stop Deviation”.

We humans have a tendency to choose the easier way to do something, and take a shortcut. The more we succeed with shortcuts, the more our brains repeat them, and the deviated way becomes normalized over time through these successful experiences.

2. Let’s reconfirm the importance of Bridge Resource Management (or BRM)
   
   

The damage to harbour facilities is due to mistakes in the handling of vessels by vessel navigators such as captains and pilots. The risk of damage is particularly high when approaching piers under rapidly changing weather conditions, and it is therefore extremely di­fficult to eliminate such accidents completely.

However, damage to harbour facilities can be reduced by close cooperation between captains and pilots rather than leaving everything to pilots. It is also important to ensure that the bridge crew understand these procedures, as required by BRM.

3. Case studies
   
   

Case 1

It is not so unusual for pilots to confirm the vessel’s position on their tablets, rather than using onboard navigational equipment such as ECDIS and radar. The following incident is a typical case during pilot conning with their tablets.

The safety investigator of the competent authority of a port reported to a master of a vessel which had just left it that the vessel had made contact with a tidal beacon in the port while the pilot was on board.

Afterwards, the VDR was analyzed, and interviews were carried out with the master, chief o­fficer, second officer, third officer, and quarter master. An underwater inspection also took place, and contact with the beacon was confirmed.

The pilot had been using his tablet to manoeuvre the vessel without reporting to or seeking assistance from the bridge team members or the fore or aft stations. Course Over Ground (COG) and Course Made Good (CMG) had been good and the vessel had been getting closer to the intended course line. Regardless of that, the pilot suddenly ordered “starb’d 10”, then “starb’d 20”, ”stop engine”, and “hard starb’d” and ”full astern”.

Why? The third officer was in position at the front of the engine telegraph, ready to respond to any orders the pilot makes. The chief officer was at the fore station in the event of an emergency dropping of the anchor. And the master had been standing with the pilot, ready to relay his orders.

The master and the crewmembers appeared to be solely focused on executing the pilot orders.

They failed to regularly verify the vessel's position, monitor COG and CMG, account for leeway, checking depths, and maintaining a vigilant lookout for potential hazards in the wider area.

Shallow waters, buoys, strong currents, strong winds, and other sea traffic including fishing vessels, all present hazards for vessels sailing in ports and coastal areas. Since it is a requirement for the bridge team to work out all the hazards for safe sailing before a voyage, the resources must be available for such a task and to be carried out. Each resource has a particular role or tasks to carry out to assess the various hazards involved.

In this incident, it is considered that deviation from particular roles and related tasks had been normalized on board, making it difficult for the pilot alone to assess the various hazards. An organized bridge system is necessary to establish good BRM, with each role and related tasks clearly described the SMS for proper resource utilization. Any deviations from the SMS must be prohibited.

Most seafarers have heard about BRM countless times and fully understand that it is essential for safe navigation. However, to establish strong BRM, all crewmembers are required to carry out each role and related tasks in accordance with the SMS. There must be no deviation from the SMS.

Basic Bridge Resource Management (BRM) at Each Level

([source] P&I Loss Prevention Bulletin Vol.35)

Watch-keeping Duties and Responsibilities at Watch Level 4

<Captain>

Takes command at the center of the bridge. In particular, when giving instructions to change course and for engine control, it is important to explain the intentions to team members if sufficient time is available. For example, to change course and reduce speed to avoid another vessel, or course change towards the next turning point and increase or decrease speed to avoid another vessel. It is also necessary to clarify switching between manual and automatic pilot to the able seaman.

<Navigator on duty>

The primary task is watch-keeping work using ARPA, while using the engine telegraph and communicating with other sections of the vessel such as the engine room and deck. Follow the instructions of the captain in communicating with engine control and other sectors of the vessel, and advise captain on steering.

<Able seaman on duty>

Focus on steering of vessel, as well as watch-keeping.

<Assistant navigator>

Verify vessel position and associated reports on course, giving successive reports on course and distance to next turning point, assistance in steering timing, and external communications via VHF.

<Increasing number of watch-keeping crews>

Focus on watch-keeping tasks, and also quick and clear reporting to all bridge crews on current situation in a clear voice.

Case 2

Most seafarers seem to understand that Master-Pilot Information Exchange (MPX) at the commencement of the pilotage is important as well as BRM. Inadequate MPX can lead to accidents. In this case, the master showed a pilot card and exchanged passage plan and maneuvering plan with a pilot once the pilot came on board. However, the master felt that the pilot was not interested in the vessel plan.

The vessel reached the turning basin at over-speed, reducing speed as it approached the berth, in accordance with the SMS. The vessel then commenced turning clockwise, with the assistance of two tugs. The master reported to the pilot that the vessel was moving at its critical speed in accordance with the SMS and vessel plan but there was no response from the pilot. Despite the speed report from the master, the pilot ordered an increase in main engine rpm and used the tugs to increase the rate of turn. The lateral distance to the berth was very short and the lateral speed of the vessel was too fast for controlled berthing when it completed the turning. As a result of approaching it at a speed exceeding that specified in the SMS, the vessel contacted the berth.

The master had to correct the pilot's maneuvering before reaching the turning basin at excessive speed or take the conn from the pilot while managing the pilot as one of the resources within the bridge team.

The problems in this case arose because the master had been on board vessels that had previously called at the port, and had placed too much reliance on the pilots.

4. Tips for loss prevention during pilot boarding
   
   

Several barriers are stipulated in the SMS, lessons learned from past near-misses, troubles, incidents, and accidents. Examples include exact speed reduction for berthing, MPX, and BRM. However, the over-reliance on the pilot easily bypassed all the barriers.

The master is required to comply with the pricise speed reduction stipulated in the SMS when the vessel is very close to the berth. Any deviation from the SMS is unacceptable.

During the navigation watch, I observed a vessel heaving up anchor and anticipated that it would cross our vessel from starboard bow. I informed the master and the OOW of the situation. However, they did not determine that it was necessary to report this to the pilot.

After heaving the anchor, the vessel had to alter the heading to starboard to give-way. The master and all the crewmembers focus on responding to the pilot’s instructions. All resources, including the master and the crew focus solely on the pilot's instructions. All resources for safe navigation to be carried out by each resource as per the SMS are easily skipped and only one mistake easily result in an accident. It makes the vessel very vulnerable to many various hazards.

Even highly knowledgeable and experienced masters and deck officers have a tendency to standardize practices that deviate from those stipulated by the SMS. Once such deviations become normalized, reverting to the original standards can prove exceedingly difficult. The key to preventing the normalization of deviation lies in two crucial elements: Firstly, fostering a culture of never deviating from the SMS standards. Secondly, establishing a system for promptly identifying and addressing any deviations to prevent those deviations from becoming normalized.

At training centers with a bridge simulator, masters and deck officers should have success experiences with suitable scenarios, each role and related tasks defined and repeatedly practiced according to the SMS. Masters and deck officers should be reminded throughout the training adhere strictly to the SMS. They learn the importance of each role, associated tasks, passage plan, MPX, and BRM, as stipulated in the SMS, and their essential role in safe navigation. They gain confidence, which can be reinforced by briefings and debriefings after each part of the training, including those focused on entering and leaving port. The discussions help the participants learn from both successful and unsuccessful events. Confidence should grow with the PDCA cycle (Plan–Do–Check–Act cycle), and become ingrained on board.

Once the onboard safety culture is established by the master and crew, it is difficult to change. When a seafarer joins the fleet after experience gained on vessels managed by another management company, he should make efforts to adapt to the onboard safety culture in accordance with the SMS. The master should correct any deviation from the SMS by crew. This is as stipulated in the SMS with the PDCA cycle.

“Make Sure That Not Deviating From SMS Becomes Standard Onboard Safety Culture”.

I hope the above observations from my experience will ensure your safe navigation!

Reference: P&I Loss Prevention Bulletin Vol.31 and Vol.35