Just as I predicted. Pilot forgot to give helm order to turn ship as normal …and nobody noticed.
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That must have been a difficult read for you Jug.
Interesting to note she is currently inbound to Fremantle.
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It was a difficult read for me as a former Pilot who regularly handled ships of that type and size.
The report seems to me to be a good one and covers just about everything.
Just a note from my point of view.
I was one of our initial team of Ultra Large ship pilots and had to make the procedures up as we went along.
One day early on in challenging conditions I was second pilot to one of my very senior colleagues. They were experiencing difficulty making the 4 tugs fast and I could see the 1st pilot becoming distracted by the conversation between bridge crew and tugs. I walked over and asked the 1st pilot for his VHF and said “ I can do that for you” which he did and I then handed the radio back when all tugs were fast.
This soon became adopted as standard procedure after that which we all found to be very helpful. If during the making fast process he needed a tug to do something he simply instructed me to do it.
Could have helped a bit here and also gets the second pilot more involved in the manoeuvre so less inclined to be using a mobile phone.
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I’m navy trained. I never gave a helm order without also observing the rudder indicator in response. Nobody ever did. That was a strictly enforced standard particularly as the helm was rarely on the bridge in sight of the officers.
It seems there’s a total uninterest in monitoring the rudder through this entry. The large helm movements in the channel should have been noted by all as a sign of a problem. I would have been inclined to stop steering a course and reverted to direct helm orders then at least someone would have been paying attention.
The failure to give a standard helm order was, in my opinion, the entire cause of the collision and everything else (although contributory)is the stuff investigators chuck in afterwards when they pull out the rule books and find things to add in.
If the pilot ‘thought’ he had given the order, why didn’t he ‘know’ because he watched the rudder indicator? Do pilots monitor the rudder indicator as I’ve described above?
Why didn’t the report probe this aspect more fully?
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The very simple answer to your question Jug is yes.
Everything else in your post above I totally agree with.
Apart from the bit about being Navy Trained which most Pilots are not. 
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Yes, absolutely. That’s a very basic requirement for anyone who has the con.
I think it’s pretty clear that the helm order was never explicitly given. To me, the real lesson here is task over-saturation for the primary pilot and the role (or lack thereof) of the secondary one. Managing four tugs, the ship’s rudder, engine and bow thruster, and interacting with the rest of the bridge crew, is a lot for any one person. In increasingly demanding situations, (equipment issues, extreme weather) it’s even easier to “forget” about one of those inputs or give the wrong order to one and fall behind the ship.
The primary pilot had an increasing workload with the rise of the wind, the impending turn, narrow channel and the gradual making up of four tugs, which were starting to be used. One of the ugly things that can rear its head in this is a confirmation bias.
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 ship was swinging to starboard. The master immediately reiterated this to the pilot and suggested increasing the engine to full ahead18 to facilitate a quicker turn. The pilot agreed and at 0614:34, the master ordered full ahead on the main engine.
That phrase/sequence as heard by the pilot may have introduced a confirmation bias to him that he did issue the hard port command to the helmsman and, indeed, with additional tug assistance and the engine increasing to Full Ahead, the ship started to make the turn to port. Unfortunately, for everyone involved, the helmsman (not incorrectly) gave subsequent helm inputs attempting to steady on the previously ordered heading. The other officers on the bridge all missed it too.
Frankly, I lay more of the blame here on the second pilot. The reason for having one is because of all the previously-mentioned demands that come with this kind of transit. He could have supported his partner and make sure nothing was missed (either a misplaced/misunderstood order or not utilizing a particular tool) or taking on specific tasks (like making up the tugs). Sometimes, all it takes to catch errors is to just stand behind the shoulder of the helmsman and take an overall view of the situation and instrumentation. Instead, his first indication of “engagement” seemed to be wondering aloud “not turning?” after being told of trouble by the primary pilot and finally getting off the phone. I suspect there was a bit of complacency in here as well with regards to this role.
All of this is aside from the weather and other factors not related to what happened on the bridge.
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I find inescapable similarities (in principle) with the Manawanui grounding, On which the RNZN did a presser today - Big changes to Navy after Manawanui sinking as court martial decision looms - NZ Herald -
Poor BRM, whether manifesting as :-
“Autopilot” (without proper input or control) or
“Helmsman” (without proper input or control),
has the same effect.
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Not only the second pilot but also both the captain and the C/M had a clear view of the rudder angle indicator and of the helmsman.
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This entire sh.tshow is an embarrassment to our overall and collective profession. Everything is wrong about it.
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3 posts were split to a new topic: Collision vs. Allision: Key Maritime Legal Differences