2019 Ever Summit crane allision report released

Increasing vessel sizes also raised as a concern.

Interesting case.

Regarding the orders to tugs… reminds me of a conversation I had with a pilot from the port of Gioia Tauro Italy a few years ago.

It was a blustery day, too much wind for mooring so we were drifting just outside the port waiting for an expected lull in the wind.

I was on the bridge wing talking to the pilot about the maneuver in and the mooring and I asked about the capabilities of the tugs; so the pilot tells me a little story.

Pilot tells me he just started working as a pilot when, after a difficult mooring operation, he ducks into a waterfront tavern for a quick beer before going home. Inside he runs into the captains of the two assist tugs he had used.

The pilot is explaining to the tug captains his thinking on the problems they had encountered during mooring when one of the tug captains interrupts him and asks “Why don’t you just let up push you in, like your father used to?”


Most vessels have open bridge wings. Pilot has his hand held radio, the master has his. Unless the pilot speaks loudly and in English who knows what specific orders the pilot is giving the tug. The tugs are rarely visible from the bridge.

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May I suggest the topic heading is a bit misleading? There were many factors involved besides the incorrect command given by the pilot. And as a strong believer in Leveson’s Law (“Human Error is a Symptom, not a Cause”) I would hope for a title that encouraged discussion of why the pilot did what he did.

Just sayin’ :slight_smile:



I can change it. Awaiting suggestions.

Well, the TSB report lists the pilot’s error as #3 in 15 findings and does not specify a single root or probable cause, so I’d suggest something like

“Canada TSB Finds Multiple Factors in 2019 Ever Summit Allision with Crane”



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I’ve never seen an investigative report ever cite a single root cause for a major incident. If they did, the reports wouldn’t be very useful.

In this case the pilot 1) took the ship in too close to the berth (10m vs. 65m recommend on the pilot card) and then gave the wrong orders to the tug. I appreciate the other factors, but I think the title pretty much sums it up.

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I usually go with the article headline or a generic type; “insert ship name here accident report released” type title.

I’ve seen this type of error many times where the pilot and crew lose track of what the tugs are doing or engine / bow thruster setting. These error usually get caught right away before doing major damage. That’s the main takeaway from the report I think, how to trap errors.

In fact @Lee_Shore I think this is related to what you said about the academy grads that go on tugs getting their boat handling skill quicker.

When I was mate I’d get sent out on the barge with a radio to assist with guiding the barge in. By contrast a junior deep-sea mate will often just be waiting for orders from the bridge. I’ve noticed this having spend a lot of time and effort getting the mates to change their habits in this regard.

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Before radios us young mates had to make some decisions on our own. Docking telegraphs didn’t exactly transmit the full picture.

Seems pretty cut and dry. Would have been a normal docking by the standards and procedures of that port, but the pilot flipped tug names in his head which resulted in the opposite effect he wanted. He didn’t catch his own mistake, nor did the tug or bridge crews, and doubled down with full on both tugs. That’s it. This happens constantly but 99.9% of the time it’s noticed almost instantly by someone in the chain.

Is there a common practice for referencing tugs during mooring operations? By this I mean do most pilots call for movement/push/pull by tug name or tug position or intended bow/stern movement? I see a couple comments stating that calling the wrong tug to thrust is common but usually corrected. Is this at all related to non-standardized communication methods?

It is related. Tug commands for docking/sailing vary port to port to a large degree. Tugs are referenced by name of tug, name of operator in the wheelhouse, position of tug, desired movement of ship, approximation of rudder commands on ship, I’ve even heard compass directions. Bell orders also vary by port and there are myriad orders and ways to say them. Somehow, it all works out in the wash by port, company and pilot association. Most of the time it does, anyways…

I don’t think it’s that common to give the wrong tug a command but I do know some pilots will always put the tugs in the same position to avoid error. In a port where all the tugs were of the same class, hp etc one pilot told me he assigns the tugs fore and aft in alphabetical order so as not to get confused.

Far more common is to give a command and then when attention is shifted elsewhere to overlook a previous command.

Mooring ops can sometimes push the limits of short-term memory.

Some places that use more than 2 tugs use numbers instead of tug names. Seems easier for all involved - easier radio communication, less to remember, much harder to get the tugs messed up. I sort of like it actually.

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A some of the ports for which I had a pilotage exemption I had demonstrate that I was familiar with the ports voice procedure with tug assisting one’s vessel.

Rarely did I have to use more than 1 tug if any, but knew the names of the tugs and watched what the vessel was doing. The mates I had were pretty sharp and did their own work as well. No pilot ever did my docking or sailing. Not to demean any pilot, (Some were former shipmates) just felt better doing it myself. They didn’t seem to mind at all. Perhaps that is what I miss the most after retiring. Not the plane rides, the long trips, the one asshole onboard that is constantly bitching, and the office up my ass for an ETA. I do miss handling the rig around the docks. Most of my engineers took good care of their shit. Perhaps not legal in union rules today, I was allowed a hand picked crew.

One problem is that saying “pilot error” tends to put an end to the discussion without really reveling any useful information about the accident.

The entire Herald of Free Enterprise could be summed up by saying it was caused by bos’n being asleep. Had that been the case none of underlying issues would have been uncovered.

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All I’m thinking is that if the pilot gives the tugs the exact opposite order that he intended to, it seems accurate to say that pilot order caused the incident. I always imagine myself in the position of the master. Could he have caught the mistake? Clearly yes. But it was still the pilot’s mistake. And there might have been more time to react to the mistake if the ship had been further off the pier. But it was another mistake of the pilot that had put them closer than they should have been.

The conclusion as to where the fault lies depends upon the method used to analyze the incident.

For the sake of augment say that the rate of incidents of this type (unintended contact with the pier) has stayed the same or decreased but that there has been a sharp increase in the number of crane collapses that this type error causes.

If this incident was analyzed using accident statistics it’s possible if not likely that there is a direct relationship between the increase of crane collapses and the increase in the number of moorings of these mega-sized containerships.

In that case it could be said that the cause is the failure to take into account the characteristics of these larger ships.


This type of accident is common in general, usually a crane does not come down when it happens.

Which is what the title of the report says - that this incident “Raises Vessel Size Concerns”.