For anyone with an interest navigation safety and the value of investigate reports this is a worthwhile read.
This is from the report:
- Investigating navigation incidents: The majority of investigations into navigation incidents indicate “human error” as the root cause of the incident. It is seldom that an investigator tries to reconstruct the incident to fully understand the circumstances of the incident. What if all actions performed to avoid the incident were in compliance with the duties of the bridge team? What if the bridge team had performed similar manoeuvres successfully in the past to avoid the incident? Our investigation methods could very well be as static as our approach to navigation audits and therefore do not consider the dynamic nature of navigating a vessel through ever changing risks. As an example, when a vessel is on a tight port rotation, we recommend our members and clients consider the heightened risks of a navigation incident and advise their bridge team accordingly. Similarly, we recommend expectations to the master are managed when the vessel is likely to call a congested port or for that matter unique port where the vessel may not have called in the past. For those on shore making commercial decisions, it is important to factor in safety of navigation in the decision process.
An arrival or departure at a familiar port is generally easier than calling to a port for the first time. This fact is not appreciated shore-side
Another important factor not fully appreciated is the impact of a schedule change. A busy ship can not plan and execute voyage at the same time. A last minute schedule change add significantly to the risk.
Many years ago, I was in a port, heading inbound and was told by the pilot what direction we would be berthing to the dock. This was agreed upon and the mooring stations informed to prepare for this type of tie up. After making the tugs fast, turning the ship upriver from the berth in the turning basin, and proceeding half the distance back to the berth, we were informed that the port actually wanted us tied up in the other direction. Miscommunication between the agents, port, and pilots had put us in this situation.
I immediately became unsettled by this change of plan as well as the cavalier nature with how the pilots were handling it. When you have a plan set in your head and have thought through how each evolution will happen ahead of time, throwing a wrench in the works increases the chances for a major incident both from the wheelhouse perspective but also for the mooring teams. Adaptability is an important skill to have, but I have never had such a feeling of impending doom or lack of confidence in what was about to happen as I did at that moment. I voiced this very vocally, was reassured that all would be fine, and proceeded to dock the ship in reverse without incident.
Nothing is routine about what we do, but certain evolutions have a hint of routine. Removing that slight level of predictability can cause the first link in the error chain to break. From there it can go south very quickly and those that are not cognizant of this make me uneasy.