Opinion

Interrupting the Error Chain - The importance of SOPs in piloting


by Captain Reginaldo Pantoja AFNI - published on 26 September 2020 998 -

Photo an text by Captain Reginaldo Pantoja - AFNI, RIO GRANDE HARBOUR PILOT (BRAZIL)

I follow, on the internet, the most recent accidents in pilotage districts of major ports, despite ECDIS, AIS, RADAR, PPU and other auxiliary tools. When my ship attended many of these ports, I was third officer, already interested in the work of the pilot.

Navigation in pilotage district is the best part of the trip because it is the most dangerous and requires the professional in charge of the manoeuvre to apply knowledge and skill with surgical precision.
I admired many pilots and captains working as a team to ensure safety. I copied many things from them that I adopt today.

As part of the bridge team, I was privileged to observe their work, behaviour, and professional methods throughout the manoeuvres.
Now, as a professional harbour pilot for over 29 years, I try to apply the lessons I learned during these times and also when I worked as a mooring master, tow master, and dock master.

Spotting Error Chain

The error chain itself is a set of actions, omissions, and interconnected events that result in an unplanned outcome. This concept is used in the maritime world to analyse accidents and detail contributing factors. Each factor is equivalent to one domino in a row, which represents the chain of errors.

A skilled risk manager works to avoid a chain of errors. If it arises, regardless of whether the ship, the circumstances or the pilot fails, you should be able to identify it and take the most appropriate professional action to break the sequence quickly.

Competence

A port manoeuvre is a complex technical process that requires qualified professional risk management. The presence of the pilot on the bridge of a ship implies the presence of a heightened level of risk – and consequently that the pilot will be competent in managing those risks.

Each manoeuvre is unique, even with the same ship and captain at the same berth. All safety protocols and standard operating procedures must be discussed, applied, and repeated. The repetition process strengthens healthy technical habits and fuels the safety culture.

The occurrences, associated with accidents when pilots are on board, make it clear in their wake a combination of factors, which, if they dealt with in time, could transform an accident into a non-serious incident.
The habit of skipping steps, making small mistakes, deviations, and violations of the standard process, weakens discipline and can lead to an accident.

Professional manoeuvre management requires a lot of discipline in complying with pre-established procedures.
Operational protocols must guide the technical decisions of the professionals in charge of managing the risk.
The lack of planning allows the development of a sequential failure that is difficult to interrupt, even by experienced pilots and captains.

In the presence of the plan, the lack of discipline to execute it correctly, too.

The following factors contribute to increasing the complexity of the risk:
1. Physiological factors such as fatigue;
2. Psychological factors, causing the professional to lose concentration
3. Opportunistic distractions as the smartphone (MikeBravo22* message).

Professionals who manage risk need to have a clear execution process previously studied and adequately safe.
Prevention strategies, including the application of training and changing poor habits, contribute to the execution of safer manoeuvres.

Communication Flow, Teamwork And Standard Operational Procedure

The exchange of technical information between pilot, captain, bridge team, tugs, pilot boat, terminal, targets, pilot station, VTS, and others involved in the process, enhances the safety of the manoeuvre.

The management of a manoeuvre requires the correct application of the knowledge acquired in the pilotage district and the compliance with a standard operational procedure.

The captain, the pilot and bridge team must be finely tuned. They must work as a safe team.
A clear communication flow must be established, avoiding deteriorating filters between the pilot and the others involved in the process.

The pilot must share the next steps with the captain and bridge team. The pilot must explain what he intends to do, well in advance, and point in the direction when appropriate. The gesture of pointing towards the terminal, tug, target, or reference point, keeps the pilot, captain and everyone around them focused on the process.
The expertise of the pilot regarding the location and the captain regarding the ship will only contribute to the safety risk management if they actively share this knowledge throughout the manoeuvre. They need to be methodical, work as a team, and follow the plan that was agreed.

Sometimes, beginners and very experienced pilots can make the same mistakes for different reasons.
The former, due to the lack of an overview of the process and little practice in its application; the latter, because they mistakenly believe that standard operational procedure does not apply to their case, convinced that they have the great accumulated skill and certainty of preparation to mitigate any situation.

Being able to interrupt a chain of errors requires amplified technical sensitivity, specific training and a lot of discipline to follow processes. The competent risk manager uses all available auxiliary tools to detect the point where the first domino starts to wobble and interrupt the error chain sequence.
Adopt a very detailed standard operational procedure is the most efficient way to manage a manoeuvre. It facilitates the detection of any deviation in the process, at any stage, allowing an early mitigation action in the error chain.

Contingency Plan

The contingency plan is an integral part of the standard operational procedure. It should be made very clear to the captain and to the bridge team, at the beginning of the MPX, so that they can help in detecting deviations and taking immediate corrective measures.
Editor's note:
Opinion pieces reflect the personal opinion of individual authors. They do not allow any conclusions to be drawn about a prevailing opinion in the respective editorial department. Opinion pieces might be deliberately formulated in a pronounced or even explicit tone and may contain biased arguments. They might be intended to polarise and stimulate discussion. In this, they deliberately differ from the factual articles you typically find on this platform, written to present facts and opinions in as balanced a manner as possible.

Join the conversation...

Login or register to write comments and join the discussion!
René Hartung Lotsenbrüderschaft NOK II Kiel / Lübeck / Flensburg, Germany
on 26 September 2020, 16:01 UTC

Well said Captain Reginaldo Pantoja.
I especially liked the small comment about the gesture of pointing. I made it a habit to do that even when giving helm orders in confined areas just to make sure that neither the crew misunderstands me, nor that I accidentally say port when I mean starboard. Sometimes it is those little things that make the manoeuvre a success.
1

Read more...

Opinion What value do 10K+ Professionals add to Safety of Manoeuvres

by CAPTAIN REGINALDO PANTOJA - published on 29 September 2022

According to many training experts, including Malcom Gladwell, from his book Outliers: Story of Success, 10.000 hours is the point in which a standard professional acquires the qualities necessary to perform any work with master skill.

2

Video The Hair-Raising Career of a Chesapeake Bay Pilot

published on 15 September 2020

Chesapeake Bay pilots guide massive cargo ships safely through the Bay's channels every day, but boarding them on a ladder attached to a moving ship is nothing short of breathtaking. Watch the video from a retired Bay Pilot.

0

Video Marine Pilot at work in the port of Hamburg

published on 17 April 2020

How do marine pilots work? Example: Bringing a bulkcarrier alongside to „Hansaport“ in Hamburg. Here the tugboats „Prompt“, „Resolute“ and „Bulldog“ are involved. The master has to rely on the pilot. One reason is, that he can‘t know how to deal with these tugs. A maneuver like this is only safe, when the pilot has a lot of practical experience. A master who is doing a maneuver like this only about once or twice a month and each time with tugs he doesn’t know in areas he hasn’t been to...

0

Video Amazing drone video: Berthing a 230m Bulker in Puerto Brisas (Colombia)

published on 5 April 2020

Using two, 66TBP tugs to assist in berthing the 90,000 GT bulker “Jin Weng Feng”. The port is “Puerto Brisas” at La Guajira, Colombia. The vessel is turned to port just outside the berth limits due to limited room in the basin with enough depth. Then she’s backed in.

0

Opinion Piloting, Autonomous Vessels, AI, and the coffee making machine

by Captain Ricardo Caballero "Themaritimepilot" - published on 15 June 2020

I am not a computer savvy. My knowledge in programming and robotics and those sort of things is nil. I get lost in the sea of social media and easily entangle myself in the web. All I have done for the last 25 years or so is to pilot ships through the Panama Canal. However, during the last couple of years I have done my best to catch up with technology, since it has enhanced our possibilities and improved safety in our field. But still, I have to admit that I am way behind the new guys in this important issue.

1

Video Suez Canal Timelapse | Life at Sea on a Container Ship

published on 6 July 2019

Tag along as we journey through Suez Canal into Mediterranean Sea.
The ship is on a 77 days voyage from Asia to East Coast United States in which we've taken the Suez Canal route. By using Suez Canal instead of around cape of Africa, this will save more than 5000 miles of fuel and time.
The time-lapse was taken over 16 hours.

0

Article First female marine pilot beats the tide in Djibouti

published on 21 May 2021

Sea transport has for many years been a reserve of men with few women getting the opportunity, especially in most African countries. But for Fatouma Ali Ahmed, women can equally steer ships just as men can do.

0

Article Updated Marine Safety Information by U.S. Coast Guard

published on 6 November 2020

U.S. Coastgard has published an update of their Recommendation for Pilot Transfer Arrangements in latest Marine Safety Information Bulletins (MSIB).

"Recent deaths of maritime pilots while embarking commercial vessels highlight the risks of operating in an
unforgiving maritime environment. To ensure the safety of all personnel boarding a vessel at sea, the Coast
Guard reminds vessel owners and operators of the requirements contained in the Safety of Life at Sea (SOLAS) Chapter V, Regulation 23 and strongly recommends that owners and operators follow the recommendations within IMO Resolution A.1045(27) – Pilot Transfer Arrangements. "

0

Video Vehicles Carrier Ship JASPER ARROW/Pilot Vessel CATAMARÁN ANTARES

published on 17 April 2020

Vehicles Carrier Ship "JASPER ARROW" / Pilot Vessel "CATAMARÁN ANTARES" #ZonaComún #RioDeLaPlata - Maneuvering of Embarking #RioDeLaPlataPilots and Disembarking #RioParanáPilot #Prácticos.- This video was filmed on board Pilot Vessel "CATAMARÁN ANTARES" and shows the moments when the Pilot Vessel was proceeding to the #BoardingStation Zona Común - Rio de la Plata, to the vessel "JASPER ARROW", to start with the Maneuvering of Embarking and Disembarking #Pilots .- Special appreciation to...

0

Article Operational notes & recommendations on Portable Pilot Units (PPU)

by United Kingdom Maritime Pilots Association - published on 2 December 2021

OPERATIONAL NOTES AND RECOMMENDATIONS by UKMPA, February 2017
The introduction of modern lightweight Portable Pilot Units (PPU) for use during pilotage has proved to be another major advance for pilotage operations worldwide.

1