Safe navigation of a ship through pilotage waters requires every part of a ship’s voyage to be planned, and for all members of the bridge team to have a common understanding of the plan. In recently completed inquiries, the Commission found that bridge resource management did not meet international standards. These inquiries featured miscommunication and a lack of common understanding among the bridge management team, and poor integration of pilots into the bridge team. The Commission has made recommendations about improving standards of pilotage, improving standards of voyage planning, bridge resource management, and about the training and use of electronic chart display and information systems. These recommendations remain open. International agencies have also identified pilotage as a safety issue.
What is the problem?
The Transport Accident Investigation Commission has recently inquired into several incidents in pilotage waters* that have resulted in groundings or contact with objects. Deficiencies in bridge resource management, an international standard for ensuring safe navigation of a ship, have been a feature of these incidents. Errors in navigation in pilotage waters have the potential to have serious consequences for people, the environment, and commerce.
* Pilotage waters are those areas in which a ship is usually required to use the services of a maritime pilot (there are sometimes exemptions). A maritime pilot is an experienced and highly skilled sailor who has detailed knowledge of a particular waterway.
What is the solution?
Bridge resource Management
The maritime industry adopted ‘bridge resource management’ as a safety and error management tool in the early 1990s. It has since become an integral part of crew training and is included in the International Convention on Standards of Training, Certification and Watchkeeping developed by the International Maritime Organization.
Bridge resource management is the bridge team’s effective management and utilisation of all available resources, human and technical, to help ensure the safe completion of the ship’s voyage. Bridge resource management includes, for example, the use of communication techniques designed to avoid misunderstandings, participants sharing the same understanding of a planned passage, and maintaining situational awareness.
The objective of bridge resource management is to ensure that the best decisions are made and any errors or malfunction of equipment are identified and corrected before an incident can develop. To achieve this objective and navigate a ship safely, every part of a ship’s voyage must be planned, and all members of the bridge team must be fully familiar with and agree to the plan. This means they can monitor and challenge the pilot’s actions effectively — good bridge resource management relies on a culture where challenge is welcomed and responded to, regardless of rank, personality or nationality.
Miscommunication and a lack of common understanding among the bridge management team under pilotage have featured in four inquiries completed by the Commission since November 2017
In July 2018, we published the report of an inquiry into the grounding of a passenger ship in Milford Sound. The pilot lost situational awareness while the ship was turning, and it deviated well off the planned track. The Commission found that the bridge team was not making full use of the ship’s electronic navigation systems to ensure that the ship stayed on track. We further found that, although the ship’s crew on the bridge noticed the ship was off its planned track, they did not bring this to the pilot’s attention until it was too late. The Commission made a recommendation to Environment Southland about its risk assessment for safe navigation within Fiordland. We also repeated recommendations previously made to the operator of the vessel about standards of bridge resource management, and training and support for the use of electronic navigational equipment.
The repeated recommendations to the operator had first arisen from an inquiry involving the same ship when it contacted a submerged object near Snares Island in January 2017 (the report to this inquiry was published in April 2018). As with the later occurrence, the Commission found the standard of bridge resource management did not meet good industry practice. (No pilot was required in the waters where this occurrence took place.) The operation of the ship’s electronic chart display and information system did not meet good practice as defined in the International Maritime Organization guidance or the standards set out in the operator’s safety management system. The electronic chart display and information system was the primary means of navigation, yet the crew was not fully familiar with the capabilities and the limitations of the equipment. The Commission made two recommendations to the operator regarding the standards of voyage planning, the bridge resource management, and the training and use of electronic chart display and information systems.
In May 2018, we published the report of our inquiry into the contact of a passenger ship with Wheki Rock in Tory Channel in early 2016. The Commission found that the standard of bridge resource management on board the ship did not meet the requirements of the company’s safety management system, or the standards in the various International Maritime Organization publications. The bridge team and the pilot had no common (agreed) understanding of the plan for the ship to make the turn into Tory Channel; and details of how the turn would be made and the influence the tide would have on the ship during the turn had not been clearly communicated. With no agreed plan, the bridge team failed to properly monitor the ship’s progress through the turn. The Commission made recommendations to Maritime New Zealand related to pilot training. In the course of the inquiry, urgent recommendations were also made to the Marlborough District Council with respect to its risk assessment for the safe navigation of cruise ships through Tory Channel.
In a fourth report, published in November 2017 and which related to the grounding of a bulk carrier, the Commission found that the incident occurred because the bridge team lost situational awareness. Because the bridge team was not adequately monitoring its progress using all available means, they did not realise that the vessel had deviated so far from the intended track. The Commission also found that: there was no formal shared understanding between the pilot and the vessel’s crew on what passage plan would be used, the vessel’s navigation equipment was not correctly configured for navigating in a narrow channel, and the standard of bridge resource management on the bridge leading up to the grounding did not meet good industry practice.
Pilotage is an issue for international agencies as well. Our peer organisation, the Australian Transport Safety Bureau has placed maritime pilotage on their SafetyWatch, the equivalent publication to the Watchlist.
The series of recurring incidents involving standards of bridge management that do not meet industry standards, and the presence of the problem in other jurisdictions, suggests that this is a safety issue that needs attention from the regulator, operators, and training providers.
Consulted with: Ministry of Transport, Maritime New Zealand, New Zealand Maritime Pilots Association, New Zealand Port and Harbour Marine Safety Code.