Opinion

Interrupting the Error Chain - The importance of SOPs in piloting


by Captain Reginaldo Pantoja AFNI - published on 26 September 2020 627 -

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.

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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.
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