The case studies that follow briefly report incidents, their causes and how they could have been avoided.
Struck a navigation mark
The ship was navigating in a buoyed channel steering towards the fairway beacon. It was the third officer’s watch. Visibility was good, the sea calm. The master was on the bridge with the watch officer. They both stood and watched as the ship drove into and demolished the fairway beacon.
Cause – operator error
The master’s instruction to the watch officer was that when he, the master, was on the bridge, he would be in charge. As a result, there was no procedure for handing over between the watch officer and the master. In this incident, the third officer thought the master would make the necessary course change to miss the fairway beacon and the master thought the third officer would change course. However, neither made the necessary course alteration. Neither knew who was in control. The need for formal procedures to hand over the watch between the master and watch officer is essential.
Struck the berth at 90°
The ship was to berth without a pilot but with tug assistance. The plan was to approach the berth head-on, drop the starboard anchor and then turn with tug assistance to berth port side to the quay.The anchor was dropped as the ship approached the berth at 90° but she continued on and struck the berth.
Cause – operator error
The master sailed directly towards the berth thinking he could drop his anchor to reduce the ship’s approach speed rather than stopping some distance from the berth and approaching with caution at dead slow speed. The speed of approach was excessive and the ship could not be controlled.
Struck a dock
The master, pilot, watch officer and helmsman were on the bridge. The pilot gave the orders and the helmsman applied them. The pilot ordered starboard helm, but the helmsman applied port helm. By the time this error was discovered, the ship was swinging towards rather than away from the berth.
Cause – operator error
It was not the practice to repeat helm orders. The helmsman thought the pilot had ordered port helm, he did not repeat the order and the pilot did not observe the rudder movement. Helm orders should always be repeated. It is best practice for the ship’s master or watch officer to repeat the helm order from a pilot to the quartermaster and for the quartermaster to repeat the order back before the manoeuvre is made.
Ship speed forward and struck the dock
The ship had just berthed and a tug was still attached. The pilot was on the bridge. Forward spring and headlines were made fast, and stern lines were being attached. Engines, though still on bridge control, were stopped. It was unlikely that engines would be used again so they were set to engine control. As this happened, the ship sped forward and, although her bow was restrained by the forward spring, she struck the dock.
Cause – equipment failure
The engine was in operation with the propeller pitch set to zero on the bridge telegraph, but to 75% forward pitch on the engine telegraph. On transfer to engine control, the pitch reset to 75% ahead. The engine room pitch control had not been synchronised with the bridge telegraph.
Telegraph settings should have been checked during handover.
Ship speed forward and struck a moored ship
The pilot was on the bridge, mooring lines had been reduced to one headline and one spring. The chief engineer started the ship’s medium speed engine and the ship sped forward, broke the two remaining mooring lines, crossed the basin and collided with a moored ship.
Cause – equipment failure
This small chemical tanker was fitted with a medium speed diesel engine and a controllable pitch propeller. There was a fault with the propeller control equipment and the propeller pitch had been set to ‘full ahead’. This was the fail-safe position. The indicator on the oil distribution box showed ‘full ahead’ pitch, but the engineer had not checked this before starting the engine. He assumed the pitch was zero by looking at the dial in the engine control room. Departure checks should require sighting the propeller pitch indicator on the oil distribution box.
Hard landing with a dock
The twin-screw ship was approaching the dock with the master operating the engine controls.There was no pilot on board because the master held a pilotage certificate. The master was navigating by visual reference to known waypoints and navigation marks. The engine could be controlled from the wheelhouse and from both bridge wings; usually the master operated the engine from a bridge wing. As the ship approached the berth, the master became concerned that the ship’s speed was not reducing as expected. He adjusted the engine controls to give full stern pitch on both engines with full shaft power. The ship’s speed reduced but it was still too great for berthing. A hard landing could not be avoided.
Cause – equipment failure
During the voyage, a fault had developed with the control mechanism on the starboard propeller and consequently the propeller pitch had frozen at 75% ahead. The ship’s engineers had noticed this but had failed to inform the master. During docking, the starboard pitch remained at 75% ahead regardless of the pitch set by the master. The fault on the starboard propeller remained unnoticed even though the propeller pitch indicator gave the correct reading.
Before berthing, an astern movement should be tested and the response of the engine/propeller pitch observed. The watch officer should routinely observe engine settings and pitch indicators.
Blackout during pilotage
The ship was navigating in a narrow part of the Mississippi River. She was a modern tanker equipped with full automation, bridge control and a controllable pitch propeller. She was sailing at full river speed and had the shaft generator engaged. Suddenly, the ship blacked out, veered to starboard and struck a moored ship.
Cause – equipment failure
There had been a split-second interruption to the power supply for the engine automation. When power was resumed, the computer reset the engine RPM and propeller pitch to the factory set default values of zero pitch and 75% power. These values differed from those that were currently set on the bridge telegraph. Nobody could understand why propulsion power had failed and the reduction in shaft power caused the shaft generator to cut out and the ship to black out. An electrical fault had caused the split-second loss of power to the engine management system. However, the ship’s crew did not realise that the equipment would reset to the default settings or what those settings were.
Where extensive automation is used for engine management, it is essential for every engineering officer to know what, if any, default settings there are.
Poor communications
The ship had raised her anchor immediately before the pilot boarded. She was under way when the pilot entered on to the bridge. The master spoke English to the pilot, but the pilot’s English was very poor and the master could hardly understand what he was saying. Nevertheless, the master allowed berthing to continue. During her first approach to the berth, the ship hit and sank a fishing boat; she struck the berth on the second approach.
Cause – flawed procedures
The lack of common language between the master and pilot prevented a proper berthing discussion. Tugs that the master believed had been requested did not arrive and the master did not properly understand the pilot’s orders. As a result, there was utter confusion.
The master should have returned the ship to the anchorage, anchored and waited until a pilot boarded who spoke a language common to both.
Tug released tow-line
Two pilots, the master and watch officer were on the bridge as the VLCC approached the berth. Four tugs were assisting, one forward, one aft and two standing by. The plan was to stop the ship about 200 metres from the berth and to push her alongside.Two tugs would push, while the two attached tugs would gently pull to steady the ship’s approach. This plan was followed, but when the ship was less than 50 metres from the berth, the forward tug released the towline and the ship’s bow swung to starboard and struck the berth.
Cause – flawed procedures
The tug should not have released the towline during what was a critical part of the berthing manoeuvre. Since the line did not break, the conclusion must be that the pilot gave an instruction to release. The pilot was not repeating in English his orders to the tugs; as a result, the master did not understand what was happening and would not intervene.
Struck a dolphin
The LPG carrier was moving towards a jetty that comprised of mooring dolphins. One of the dolphins was hit and damaged when the ship’s bow veered to starboard while she was moving astern under full astern power.
Cause – failure to understand ship’s characteristics
The ship was fitted with a right-handed propeller,which produced a pronounced transverse thrust when operating at a light draught and when moving astern. As a result, the ship’s stern would move to port. The master and pilot had not realised that transverse thrust would be sufficiently strong to cause the ship’s bow to swing and did not allow for it.
It is important for ship masters and watch officers to understand the manoeuvring characteristics of a ship. At a suitable opportunity,manoeuvring should be practised. It is especially important to be familiar with the effect of transverse thrust.
Struck a moored ship
The ship was being towed stern first against a flood tide towards the turning basin.Two pilots were on the bridge along with the master,watch officer and helmsman.Two tugs were assisting. The ship had not quite reached the turning basin when the pilot started a 180° turn. During the turn, the tide pushed the ship’s stern towards the riverbank and so engines were put to full ahead to prevent contact. However, the ship sped forward and struck a moored ship on the opposite bank with her bow.
Cause – failure to understand the ship’s characteristics
The turn had been begun before the ship was in the turning basin. Consequently, there was less room to turn. Tide had been underestimated, and when the ship’s stern became dangerously close to the riverbank, the pilot applied excessive engine power. Although the pilot card had been sighted, there had not been a detailed discussion of the manoeuvre between the master and the pilot. The turning position had not been indicated on the chart and the master was unaware of the pilot’s intentions. A full discussion of the intended manoeuvre between the master and the pilot is essential before the pilot is given control.
Struck a dolphin
In order to berth, it was necessary to swing the ship through 180° and approach at an angle of approximately 45°. However, on this occasion, the ship came out of the turn to the west of the jetty. This would result in an approach angle of 10° rather than 45°. There was a four knot current that would push the ship towards the jetty. As the ship approached the jetty, the strong current swung her bow to port and towards the berth. Corrective action was taken and additional starboard rudder applied, but the bow still swung towards the jetty and hit a mooring dolphin.
Cause – failure to understand berthing requirements
The angle of approach to the jetty was too shallow; contact is likely when trying to berth at a shallow angle. After completing the turn and finding the ship too far to the west of the approach line, the master should have taken her back to the turning basin and swung her around again. The approach angle should have been agreed between the master and the pilot at the start of the manoeuvre. As it turned out, the pilot attempted to ‘muddle through’ rather than to start again. The master allowed him to continue.
Struck a moored ship
On this ship, it was usual for the master to put her alongside the berth after taking control from the pilot. The discussion between the master and pilot had been minimal. On this occasion, when the master took control, he saw that the space on the berth was small and just large enough for his ship. Also, he would be berthing against a difficult knuckle. It was night. The ship had a bow thruster.A tug was in attendance.As the ship approached the berth bow first, she hit the ship moored ahead.
Cause – failure to understand berthing requirements
Inadequate discussion between the master and pilot resulted in the master having insufficient time to plan the berthing before attempting the manoeuvre. It would have been better to berth stern first, using the tug and then the bow thruster to push the bow alongside. This would have become apparent during a discussion on berthing.
Struck a river berth in high wind
The ship had arrived at the lock entrance where she was met by two tugs, both of which would be needed to see her into the lock. Wind was gusting force 10 and the ship was very exposed. The crew were unable to attach a line to either tug and the ship was blown on to a mooring dolphin.
Cause – failure to allow for wind
Weather conditions were very poor and strong winds were making navigation difficult. However, tugs had arrived only as the ship was reaching the lock, when in fact they should have been asked to attend when the ship was in the open channel.
