Full report is here:
Full report is here:
This is an interesting one. On the surface, it’s simple enough: The guy went too fast, shoulda kept some power in reserve. However, the report somewhat conspiciously fails to ask why. It’s tempting to theorize that the Houston pilots, being at the very top of their game and members of a large organization of extremely competent ship handlers, have gotten too comfortable with operating on the edge of the envelope.
However, I’m not sure that this is the case. It’s hard to nail it down, but the guy (Pilot 2) seemed uncomfortable with the situation, from the comment about being all over the place, criticizing the ship’s handling characteristics, to the way he is wording things in general. I have to wonder if the uncommon number of verbatim quotes is the report writer’s way of expressin this notion, or if I’m imagining things.
If this admittedly thinly founded inference is true, the obvious question is why in the world a man of such competence, at the edge of his seat, would order nav full when he did? Are Houston pilots paid by the transit or by the hour? In other words, is there commercial pressure for the pilot to expedite the transit as fast as possible? If so, the root cause should be easy enough to address; The Houston Pilots Association is plenty powerful enough to establish a paradigm where such pressures don’t affect operational risk.
Another possibility is that Pilot 2’s decision stemmed from peer pressure to operate as fast and smoothly as possible, to avoid being seen as incompetent. I feel that the NTSB would have done well to explore this avenue of inquiry in greater detail, rather than just recommend that speed be reduced and the engine be kept in the maneuvering regime in the Bayport Flare. There has to be some kind of organizational failure at work here.
Quite unrelated, I find this bit to be a bit odd:
In a deposition taken in October 2019, the second officer stated that he did not depress the bypass button on the bridge because “we might lose our engines in the middle of the channel…it could have created a drastic changes of major—major damage to the engine.” He added that he had been trained by the vessel’s current and former chief engineers that depressing the button would damage the engine, and that pressing the button required the permission of the master or chief officer.
What would be the purpose of telling the crew this? To keep them from pressing the buttom randomly, because it’s funny when the black smoke comes out? And did they actually believe that the EOT had a handy “damage the engine” button?
Yeah, there’s a lot in that report.
Could be that the accident rate in the Houston Ship Canal is considered acceptable. Making it safer would require reducing the output of the entire system.
As far the situation with the EOT, a Nabtesco, same one we had. With a fully loaded ship a by-pass order won’t give much more before another load limit of some kind is reached. Just a few RPM at best.
Pilot 2 requested that the crew turn off all radar alarms, telling the crew
that since the vessel would be passing other vessels at short distances throughout the transit, the
alarms indicating closest point of approach would be sounding often and would be a distraction.
The safety management system (SMS) for the Genesis River’s management company required that
both of the ship’s radars be kept on at all times while in areas of high traffic density and near
navigational hazards. However, during a postaccident interview, the master told investigators that
the alarms on the vessel’s automatic radar plotting aid (ARPA) system that displayed the radar
data could not be turned off, so to comply with Pilot 2’s request to silence the alarms, he instructed
the officer of the watch to put the radars in standby.
10 The SMS also required that one of the
vessel’s electronic chart display and information systems (ECDISs) be regularly monitored, but
the master stated that alarms on these systems likewise could not be silenced, so he told the fourth
officer to turn off the online ECDIS as well. The Genesis River had two ECDISs on board, which
met the International Convention for the Safety of Life at Sea (SOLAS) requirements for redundancy.11 With the ECDISs off, the master instructed the fourth officer to monitor the vessel’s
position visually by sighting landmarks, navigation buoys, and beacons, and by monitoring the
pilot’s PPU. Pilot 1 told investigators that he was aware that the ECDIS was off and that the radars
were in standby, but he was not concerned because he had the PPU to rely on and had good
visibility for seeing navigation aids.
I am impressed.
On the pilots request to disable all(sic) radar alarms ship’s crew just switch over both(?) ARPA to standby mode and completely turn off ECDIS. The highest specific vessel transited congested water without running radars and switched off ECDIS. Judging by pilot and NTSB inspectors as well reaction this situation was not unusual, let say common practice.
The faster you get to the dock, the faster you get to go home. That’s how they get paid.
Because it is. The some alarms can’t be disabled and are extremely distracting, so they are secured. As far as ECDIS, the pilot had a PPU unit that was probably better than the shipboard model.
Doesn’t seem especially relevant to the collision but this doesn’t seem accurate.
In my experience on several ships with this (or very similar) Nabtesco system “NAV FULL” is specifically about 72 RPM. It is a “bell” same as half or full.
NAV FULL is selected by unlocking the handle by pushing the thumb button on the left and setting the level at the NAV FULL position. The difference is that unlike the other bells it is above 58 rpm (FULL) which means instead of just coming quickly to 72 RPM the Load Up program starts so it takes a few minutes to reach 72 (NAV FULL).
The was no need for the 2nd mate to call the ECR he could have increased ordered RPM just by unlocking the level and pushing it forward or dialing with the fine tuner to whatever RPM he wanted. Hitting the by-pass button would have disabled the load-up program and the actual RPM would have increased as fast as the other engine limits allowed.
Any PPU will never be “better” than a any ECDIS and cannot be use as an official replacement.
Properly set up ECDIS must always be on when the vessel is not safety moored.
Bridge team (included pilots) should use all available tools to proper monitoring ships movement, especially both ARPA.
These are basic principles that cannot be discussed.
It’s true that some alarms cannot be disabled but in almost all cases the parameters of the ECDIS or ARPA can be adjusted such that they do not sound an alarm to the point they become a distraction.
The deck officers may not know how to do it, most do not.
I wonder how/if the CG jammed up the towboat captain/mate?
It would be interesting to know what license penalties the USCG imposed on the tug master, mate, and ship pilot.
My guess would be a few months of suspension for the master or mate, but probably nothing for the pilot.
Regardless, it is not uncommon.
And how exactly would an energized ECDIS or radar prevented this incident?
The question is why was the Pilot given the revolutions? The Master had been to the port in that capacity and the 2/M had made many calls to Houston, so they were aware of landscape and how crazy that place can be.
I remember trading in Houston back in the day and the Pilot wanted 20 minutes notice. I promptly declined. I told him it wasn’t safe. He was angry, but no one had to call the lawyers.
In the report the NTSB said the tug crew’s actions were “reasonable”, and IMO they were, but the CG always likes to go in dry.
I am not familiar with the telegraph being discussed here but in my calls to Houston we proceeded at manoeuvring full ahead for sections of the canal giving 16 knots. Full away was 24 knots and left to its own devices it took about 60 minutes to reduce back to manoeuvring full ahead. Any request for turns more than manoeuvring would have been refused.
The Genesis River was apparently at NAV Full (73 RPM) at 15:12 on this graphic but only at 12.6 kts.
Exactly in the same way as for instance the Safety Recommendation M-21-1.
The safety board can not be limited only to the direct causes of the accident. This transition/pilot passage was unimaginable to me. What about international regulation, flag and coastal state rules, company procedures and finally industry recommendation?
There was a lot of discussion here about BRM. Do you accept such bridge teamwork and do you agree that the ships thus managed will sail in your waters?
Nothing particularly special about the EOT.
If RPMs at FULL (58 RPM) and below are called “maneuvering speeds” and all RPMs above FULL were considered “sea speeds” than this EOT has one extra bell in the sea speed range at 73 RPM called “NAV FULL” which is within the range controlled by the load up/down program.
The NTSB report calls NAV FULL a “mode” which I believe is not correct.
Doesn’t answer the question.
Edit - The ship was handling poorly and needed engine to stabilize the heading after turning. Sometimes, when on an even keel, when the vessel develops headway the will handle like it is down by the head (which it is). Kind of reads like that’s the case.
It does sound like steering a ship down by the head.
I thought this was interesting; it’s not just the fact that with the engine at sea speeds there is not much ability to give a “kick ahead” to regain control.
Rudder control forces increase roughly as the square of the speed while bank forces increase with the cube of the speed.
From the report: