Based on MAIB Safety Digest 1/2025, Case 12, published April 2025 by the UK Marine Accident Investigation Branch (MAIB).
The digest provides anonymised, instructive case studies from recent maritime accidents, aiming to raise safety awareness and promote learning across the industry. This particular case involves a serious collision between a cargo vessel and a pilot launch during a night-time departure — a scenario that highlights critical failures in pilotage coordination and bridge resource management.
During a routine late-night departure from port, a general cargo vessel got underway with a pilot embarked. The vessel cast off and began maneuvering through a constrained harbour channel toward open sea, guided by the pilot. The operation required precise coordination due to the narrow exit between two breakwaters.
As the ship progressed, the pilot became absorbed in a VHF radio conversation with port control. The discussion was not related to the vessel's navigation but focused on logistical arrangements for the pilot's next assignment. The dialogue soon devolved into unrelated chatter. The master, while able to hear the exchange, did not understand the content, as it was conducted entirely in the local language.
The digest provides anonymised, instructive case studies from recent maritime accidents, aiming to raise safety awareness and promote learning across the industry. This particular case involves a serious collision between a cargo vessel and a pilot launch during a night-time departure — a scenario that highlights critical failures in pilotage coordination and bridge resource management.
During a routine late-night departure from port, a general cargo vessel got underway with a pilot embarked. The vessel cast off and began maneuvering through a constrained harbour channel toward open sea, guided by the pilot. The operation required precise coordination due to the narrow exit between two breakwaters.
As the ship progressed, the pilot became absorbed in a VHF radio conversation with port control. The discussion was not related to the vessel's navigation but focused on logistical arrangements for the pilot's next assignment. The dialogue soon devolved into unrelated chatter. The master, while able to hear the exchange, did not understand the content, as it was conducted entirely in the local language.
Credit: UK MAIB
Credit: UK MAIB
With the vessel on a steady outbound course, the pilot instructed the master to increase speed to 12 knots. Ahead, the pilot launch was making slow way out of the harbour, presumably positioning itself for the pilot’s disembarkation. There was no communication between the vessels regarding movements or intentions.
Approaching the narrowest part of the channel, the master noticed the pilot launch closing in dangerously on the port bow. When prompted by the master, the pilot attempted to establish contact with the launch. However, at that moment, the launch unexpectedly altered course to starboard — directly across the cargo ship’s path.
Despite immediate engine and helm orders, a collision was unavoidable. The cargo ship struck the pilot launch’s starboard quarter. The launch took on water rapidly and sank. All four launch crew members escaped uninjured and were rescued by two nearby tugs.
Key Lessons:
Approaching the narrowest part of the channel, the master noticed the pilot launch closing in dangerously on the port bow. When prompted by the master, the pilot attempted to establish contact with the launch. However, at that moment, the launch unexpectedly altered course to starboard — directly across the cargo ship’s path.
Despite immediate engine and helm orders, a collision was unavoidable. The cargo ship struck the pilot launch’s starboard quarter. The launch took on water rapidly and sank. All four launch crew members escaped uninjured and were rescued by two nearby tugs.
Key Lessons:
- Bridge Resource Management (BRM): Effective coordination between the pilot and bridge team is essential. In this case, the pilot was disengaged, and the bridge team failed to assertively integrate him into the navigational decision-making process.
- Situational Awareness: The pilot launch crew was distracted and failed to maintain a proper lookout as required by COLREGs Rule 5. Likewise, the bridge team missed opportunities to issue sound signals that could have alerted the launch in time.
- Communication Protocols: There was no proactive VHF communication between the pilot vessel and the cargo ship. Five short blasts — the standard danger signal — were not used.
- Risk-Based Decision-Making: Despite the accident, the master made the correct call to maintain control of the vessel and clear the narrow channel to avoid further hazard. He returned to port as soon as it was safe.
Conclusion:
This case serves as a sobering reminder that pilotage is not a routine formality — it is a high-stakes, shared responsibility. Pilots must be fully integrated into the bridge team and maintain complete situational awareness. Masters and bridge teams, in turn, must remain assertively involved and not hesitate to challenge or question unclear actions. Coordination failures, especially during high-risk phases such as departures in confined waters, can rapidly escalate into major incidents — as this collision clearly shows.
Source: UK Marine Accident Investigation Branch (MAIB), Safety Digest 1/2025, Case 12: "A Crunchy Exit", published April 2025. Available at: www.gov.uk/maib
This case serves as a sobering reminder that pilotage is not a routine formality — it is a high-stakes, shared responsibility. Pilots must be fully integrated into the bridge team and maintain complete situational awareness. Masters and bridge teams, in turn, must remain assertively involved and not hesitate to challenge or question unclear actions. Coordination failures, especially during high-risk phases such as departures in confined waters, can rapidly escalate into major incidents — as this collision clearly shows.
Source: UK Marine Accident Investigation Branch (MAIB), Safety Digest 1/2025, Case 12: "A Crunchy Exit", published April 2025. Available at: www.gov.uk/maib
