As a retired Pilot who was and still is very proud of my profession……I find this interim report extremely embarrassing.
I expect better of my cloth and also lay some blame at the feet of management. Why was this vessel permitted to enter under these out of limit conditions? Where was the mobile phone usage policy?
Once again, I make the obvious point. There was no apparent decision to turn to port and maintain the turn when the turn should have started.
The ship’s image at 061516 above should have shown the ship mid turn.
Action to make the turn was started at 0614:24
Despite the helm being maintained nearly at hard port, the vessel was heading almost 087°, making good 7.5 knots, with a 1°/min rate of turn to starboard.
As the primary pilot was conning the vessel from the front of the wheelhouse, the secondary pilot was stationed at the rear and continued to be engaged in their phone call. At 0614:24, the pilot
instructed Svitzer Emma on the port shoulder to pull back with half power. The helmsman then reported aloud that the wheel was on hard port, but the vessel was swinging to starboard. The master immediately reiterated this to the pilot and suggested increasing the engine to full ahead11 to facilitate a quicker turn. The pilot agreed and at 0614:34, the master ordered full ahead on the main engine.
With the helmsman continuing to maintain the helm nearly at
hard port, the Maersk Shekou’s bow started slowing swinging to port.
By 0615:16, the vessel was making good 7.1 knots and continued to swing to port, achieving a maximum rate of turn of 9°/min. However, as the heading came around to 086°, the helmsman brought the helm to midship and then to starboard 33° for a brief period before returning it to midship. The helmsman’s actions resulted in the vessel’s port swing being arrested, and the vessel being steadied on a heading of approximately 083°, into the path of A and B berths at Victoria Quay.
The helmsman’s last order was to steer a course of 083°
Not using the rudder by helm order.
Very good helmsman!
As far as checking the rudder angle indicator, I agree with @Ausmariner that it depends on where it is located.
On the ships I was on the rudder angle indicator was located where it can be easily seen by the helmsman, directly above where the pilot typically stands. Checking the indicator requires the pilot take half a step back and craning their neck up to see it,
In my experience pilots do not check the indicator unless they see or feel the ship turning the wrong way.
KC,
You may be confusing me with @OneEighteen who made this statement.
I was an absolute stickler for monitoring the RAI, irrespective of its location and would fail trainees during check Pilotages if they did not monitor constantly. In my port, a wrong way helm could very quickly lead to a grounding.
For Ausmariner and Kennebec -
I might have been misunderstood.
For a pilot anywhere, checking the proper execution of a rudder order is paramount, whether it’s in a convenient location or not. There are alternate ways to check though. If the rudder angle indicator is in a bad spot the pilot can watch the helmsman’s hands to see if the order was executed properly. Sometimes the pilot might not obviously turn around and look behind, but he can see the reflection in the window. One ship I piloted the captain ingeniously used two mounted truck side mirrors to get an image just above the conning station. (Two mirrors to correct the orientation) Sometimes you can see the bridge wing monitor. The point is, you have to watch to see the helmsman did what was ordered.
What I was trying to convey is the possibility that the pilot did check the RAI and it was hard port at the time he/she checked. It was then mentally crossed off the list. But if the indicator was in a bad place it might not have been noticed that the rudder did not stay at hard port… that the helmsman was acting on his instructions as he understood them - to steer a course.
A little off topic, but it has been a long time since the link between the ship’s instruments and the pilot connection has been updated. Radar picture would be an obvious addition, but a link to the RAI would be an easy addition, well within current tech. The ability to glance at the screen in a convenient place would be an important safety measure.
Why not put some icing on that cake? With voice recognition software the pilot unit would be able to compare the verbal order of the pilot to the results sent by the connected RAI. Pilot says “port 10”, computer senses starboard 10, sounds a warning and makes the screen flash. Very simple tech.
I agree that it’s more likely that the helm position error would have caught had the second pilot not been on the phone.
It was a Honolulu pilot that first told me about the role of short-term memory in the context of piloting.
Here’s the first google hit:
Cognitive correlates of maritime pilots’ human errors
From the paper at the link - called WM (Working Memory) here:
As pilots have to handle a complex set of information (Cameron, 2001, ONETOnLine, 2022, Orlandi and Brooks, 2018), WM (Working Memory) should be put to work to deal with the burden of an excessive mental workload which is considered as a risk factor on-board negatively affecting situational awareness and decision-making (Fan et al., 2023) causing human error in occupational settings (Main et al., 2017). Thus, this necessitates pilots to be high-performers on WM tasks.
Love this idea - always a great idea to engineer out human error when you can.
Checking the RAI after a full rudder command isn’t really relevant in this case because the command was never given. Instead, both the captain and the 2 pilots were apparently focused on the thruster, main engine and the 4 tugs.
Trapping errors in general is a shared responsibility of both the crew and the pilot.
KC,
Throughout this incident there was no shortage of errors which required trapping……one might use the description “litany”.
The headline is bothersome to me, like it assigning some blame to the helmsman. The pilot was conning, the helmsman is not acting independantly, he/she was not working against anyone, he was working FOR the conning officer, who was not properly ordering the helm.
Yes, agreed, changed it. The forum title anyway, can’t change the article headline.
I’ve experienced the confusion between a helm order and a report of rudder position.
The helmsman has been given a course to steer, the engine is stopped, ship loses steerage and the helmsman reports “helm is hard port, heading is falling to starboard”. The command “hard port” is given, meaning the previous order to steer a course is canceled, keep the rudder hard port.
If it’s not made explicit that the previous course order is canceled by the new helm command, when the engine is restarted the helmsman may resume steering the course rather then keeping the wheel hard port as expected.
So there is some ambiguity there.
Edit: This is the relevant part of the interim report:
At 0614:24, the pilot instructed Svitzer Emma on the port shoulder to pull back with half power. The helmsman then reported aloud that the wheel was on hard port, but the vessel was swinging to starboard. The master immediately reiterated this to the pilot and suggested increasing the engine to full ahead11 to facilitate a quicker turn. n. The pilot agreed and at 0614:34, the master ordered full ahead on the main engine.
That is apparently the moment when the information (wheel is hard port) is understood by the pilot but without the correct context (helmsman is steering course 083°).
I am not kidding or teasing . I am damn serious abt it.
I have it all .All shebang .
Cheers
The whole thing is not big as per below and will be residing in my google drive and accessible via provided link.
Some recent good news. Movement at last.
I was talking with the CEO of the Leeuwin Ocean Adventure Foundation aboard tonight and he has received confirmation from the ship’s insurers that they will provide funds to repair the ship immediately in the interim and obviously squeeze that out of the party eventually found at fault.
He’s expecting the ship to be sailing again by the end of the year.
The ship will be lifted out in a couple of weeks for a full docking and all necessary underwater work. Orders have been placed for quantities of Douglas fir from N America for the dozen timber spars, and steps are in hand to build the steel lower masts and repair/renew rigging and sails.
Volunteers and crew are busy checking and testing salvaged rigging and preparing for docking.
helmsmen make mistakes, but they are never responsible - the person at the conn is always responsible for the movement of the ship -
Very many thanks.
My discussions tonight with the CEO suggested it’s over both our heads (don’t interfere - they know what they’re doing etc) and that our insurers were working to gather everything for the case for a slam dunk, can’t be argued with case eventually.
I’ll send your advice on nevertheless and suggest there’s much to be gained from the documents you have and that it could be important for their case.
I’m not sure how to access your link. Did you send it separately?
