Risk in navigation is often attributed to individuals — the pilot or the Master. This is a convenient simplification. In reality, many marine incidents do not originate from individual failure, but from structural ambiguity in decision-making. They emerge in the space between roles.
Pilotage is built on a dual structure:
- the pilot provides local knowledge and navigational advice
- the Master retains ultimate command responsibility
Can you provide an example from an actual incident that was caused by “structural ambiguity in decision-making”?
An example of an actual incident is the Ever Forward grounding in Chesapeake Bay.
During the course of the outbound transit, investigators discovered the pilot made a series of five phone calls amounting to over 60 minutes. He also sent two text messages and began drafting an email immediately before the grounding occurred
The pilot was hired to pilot the ship. Why didn’t the OOW call the captain as soon as the pilot began to attend to other business? It should have been unambiguously obvious that the pilot required correction.
The Maryland Pilotage Board plugged that particular gap by passing a rule prohibiting the use of phones while piloting but the larger issue remains.
With respect, the third sentence of the cited article states “In reality, many marine incidents do not originate from individual failure, but from structural ambiguity in decision-making.”
To me, the example you have provided originated from individual failure. There was no ambiguity about who was giving navigational commands on the bridge.
Like last week’s discussion about “who has the conn?” we have another attempt to make a mountain out of a molehill.
Un abrazo
How about this one.
See page 10
I believe the practice now is to enter the river stern first and not use the swinging basin. With a bridge team of one trying to establish who said what is difficult.
You’ve definitely identified a case where confusion about who was doing the docking contributed to an incident. Such a simple thing to avoid, just common sense. The captain should have told the pilot he was taking over and the pilot should have clarified his role verbally when the saw the captain had moved the rudder without an order.
IF that is when the confusion began. Just guessing, maybe the pilot thought he gave control to the captain about a berth length or two before the basin, but the captain didn’t understand or hear the pilot.
If the ship positions shown in figure 12 are accurate it looks like the bow thruster was a total fail. In every position drawn the bow is further to the left. Was the thruster full right all the time? I didn’t read anywhere that the investigators had tested the thruster to see if it was actually working.
In any event, they said only one minute elapsed between when the captain put the helm over and when they ran aground. Sounds like the situation was 5 pounds of poop in a 3 pound bag already. At the one minute mark it would have been hard to recover. Captain could have done anything with the rudder and none of it would have mattered at that point.
The linked article in the OP is very short, an example might have been helpful.
My take on the article is it’s intended to create a shift in perceptive. The way it’s framed is not on that first link in the error chain but how to manage emerging risk.
From the article:
The most dangerous situations onboard are not always those where nobody sees the risk. They are often the situations where several people see it — yet no one fully assumes authority to decisively act on it.
It’s often the case framing incidents or events in more than one way can be useful.
Edit: The grounding of the Algoma Verity in the Delaware river is probably a good example where this framing would be useful. Both the captain and the pilot recognized the risk, the pilot said he was “running out of room” and the captain pointed out the ship was outside the channel but neither one of them took any action to rectify the situation.
The effect of the bow thruster would have a bit to do with how much headway the ship had on. Once they had their head in that basin I would hope the vessel would be stopped and maybe even backing a bit.
The report said they were under 2 knots down to zero. I’d ordinarily ask if a bow thruster is ineffective at 2 knots what’s good is it?
In my experience more a question of degree - with anything more than a knot or two of headway you just lose to much leverage off the pivot point - it is still effective, just not as much when you are stopped, and way way less than with sternway. All that said - with exceptions of course, most bow thrusters are way better at rotation than they are at changing direction.
Oh - more importantly - you are right of course - under 2 knots it should be able to move the bow.
An aside - no clue if it impacted this case. But one skill that I believe good pilots are either born with or develop over time is the ability to see real motion at very slow speeds. Dopplers help those of us without that experiance, but I have often been amazed at this skill, which I am not even sure that the pilots themselves know how good that is.
That ability is tough. I couldn’t do it in an anchorage or where there were no structures nearby to relate to. The gps was a real help to me.
The ship’s maneuvering diagram was worthless to a pilot, but a poster showing how many ship lengths needed to stop the ship from 4 knots headway would be very useful. Results of zig-zag test too.
I used to berth a vessel in similar conditions also equipped with a Becker rudder and bow thruster. There was very soft mud where the swinging area was and rocks the other side of the estuary. With minimum headway the rudder was put hard over and half ahead to get the vessel swinging, bow thruster full to starboard. As soon as the swing had started, midships and half astern. Sometimes full astern, oops another gin for the chief. Tide range 4 metres, vessel 400 Teu geared feeder ship.
The Lagik grounding has similarities to what the article in the OP is about but also some differences.
The most dangerous situations onboard are not always those where nobody sees the risk. They are often the situations where several people see it — yet no one fully assumes authority to decisively act on it.
In this case the captain did assume at least partial authority to act decisively. He took the helm, apparently without making it clear to the pilot what he was doing.
The captain had been in that turning basin but on smaller vessels and may have been seeing risk where it didn’t exist. He might have been misjudging the distances.
