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

Article Pilots and ship´s Captains

by Marine Pilot Luis Vale, Portugal - published on 23 August 2019

Lately there has been a considerable increase in opinions of seagoing ship´s masters complaining about pilotage services, expressed whether as LinkedIn articles and comments or in some reputable industry magazines.

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

Video How Harbor Pilots Dock Massive Cargo Ships (Full Process)

published on 6 May 2024

In this video we follow along with Capt. Dane of the Palm Beach Harbor Pilots Association on a windy Saturday morning as he brings in a massive bulk carrier cargo ship into the Port of Palm Beach. This vessel which has a draft of 27 ft, and a beam of 99 ft is the maximum allowable size vessel allowed to transit into the port due to the shoaling going on that forces all vessel to have a maximum operating draft of 29 ft. No room for error. Also featured in this video is a regular cargo vessel...

0

Video Construction of Panama Canal from 1908 and 1914 in color! Part-1

published on 13 October 2020

Spectacular (silent) film footage of the construction of the Panama Canal more than a century ago. The film shows the construction of the Miraflores and Gatun locks in detail as well as the digging of "The Culebra Cut" including steam trains, steam shovels and steam dredgers at work and scenes of the locks an the Canal in its first days op operation in 1914. Wikipedia: The Panama Canal (Spanish: Canal de Panamá) is an artificial 82 km (51 miles) waterway in Panama that connects the...

0

Video How to Launch a Pilot Boat–Behind the Scenes at Point Hope Shipyard

published on 20 June 2025

Welcome to Point Hope Shipyard in Victoria, British Columbia, Canada. In this video, I follow the float off of the Pacific Navigator, a hardworking pilot boat that serves the Port of Victoria and Ogden Point. We watch as the vessel is pulled along the marine railway, rotated on the turntable, and positioned onto the cradle. Once secured, the cradle lowers to float-off depth, and the Pacific Navigator fires up her engines for a short harbour spin before returning to duty. Some segments,...

0

Article BELCINAC – Compact pilot boat to operate in France’s Seine river

by Baird Maritime - published on 22 November 2023

French operator Seine River Pilot Station has expanded its fleet of pilot boats with the recent acquisition of a newbuild vessel from local builder Chantier Naval Delavergne.

0

Video Port of Tyne Pilotage: Pilot Boat Collingwood

published on 24 March 2025

navigate the Port of Tyne? Join me aboard the pilot boat Collingwood as we put pilots on and off ships! Experience the skill, precision, and teamwork it takes to guide vessels safely through one of the UK's busiest ports. From close-up action on the water to behind-the-scenes insights, this is a must-watch for anyone fascinated by maritime operations.
📸 Follow my photography journey: [Your Website or Social Media Links]
👍 Like & Subscribe for more behind-the-scenes content!
#PortOfTyne...

0

Video Know your Pilot Ladder in less than eight minutes

published on 13 November 2020

As part of Maritime Skill Enhancer Platform created by Navguide solutions, we give you a comprehensive inspection of your Pilot ladder, keeping you compliant, safe and ready for any inspection.
All this - in less than eight minutes!
Maritime Skill Enhancer is going to be the most practical platform to learn your day to day Maritime Skills, in matter of minutes. We are coming soon.
Subscribe to this channel and stay updated.

1

Video Pilotage in Malaysia

published on 27 January 2022

#pelindo #pelabuhan #pelaut #kapal #maritime #Sungai siak #indahkiat #Perawang #Peakanbaru

0