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 St Johns Bar Pilot Association

published on 17 January 2020

A collection of action from the St Johns Bar Pilot Association In the early 1800′s as the commercial ports along the St Johns River began to develop, a select group of brave and skilled seafarers would row to sea to meet arriving cargo sailing ships. These daring individuals would use their extensive local knowledge to safely guide the sailing ships across the treacherous sand bars that guarded the river entrance. This was the origin of the St. Johns Bar Pilots. Initially it was a bit of a...

0

Opinion Pilotage Wisdom

by Frank Diegel - published on 1 September 2020

"An old experienced pilot sometimes loses a ship by his assurance and over confidence of his knowledge, as effectually as a young pilot does by his ignorance and want of experience."
Let us remind ourselves every day of the principles of safe seamanship...

0

Video La station de pilotage des ports de Casablanca et Jorf-Lasf

published on 16 July 2020

The pilot station of the ports of Casablanca and Jorf-Lasfar operates in accordance with the 1937 Dahir on the reorganization of the pilot station of the port of Casablanca, which regulates all aspects of the organization and operation of the station, including the recruitment of pilots, as well as the pension and relief fund.
With the advent of Law 15/02 in 2005 on port reform, the station spontaneously adhered to it by creating a commercial company in application of article 13 of the said...

0

Video 30 Days Timelapse at Sea | 4K | Through Thunderstorms, Torrential Rain & Busy Traffic

published on 6 July 2019

Follow my adventures on Instagram! http://instagram.com/Jeffrey.hk
30 Days of Timelapse, about 80,000 photos combined. 1500GB of Project files. Sailing in the open ocean is a unique feeling and experience.I hope to capture and share it for everyone to see.
Route was from Red Sea -- Gulf of Aden -- Indian Ocean -- Colombo -- Malacca Strait -- Singapore -- South East China Sea -- Hong Kong

1

Opinion Pilots are not Advisors to Masters

by Karolina Cirjak, Consultant Master Mariner at KC Maritime Consultancy Ltd. - published on 30 November 2024

This article was first published back in February 2022: According to the International Group of P & I Clubs’ “Report on P&I claims involving vessels under pilotage 1999-2019”, over the last twenty years, there were 1,046 incidents in which pilot error either caused or contributed to those events.

7

Video Open Waters Program Launch - Maritime Career Development Program

published on 21 January 2022

Open Waters Program Launch - Maritime Career Development Program
Louisiana River Pilots Association - Crescent River Port Pilots - New Orleans-Baton Rouge Steamship Pilots Association

0

Video Self-righting test and arrival of Pilot Boat "Hirondelle de la Manche" (2017)

published on 20 September 2021

Arrivée au Havre de la pilotine Hirondelle de la Manche

0

Article GPS interference and jamming on the increase

published on 2 October 2020

Ships have reported an increasing number of cases of significant GPS interference and jamming in recent months. The geographic areas with more than one reported incident include the eastern and central Mediterranean Sea, the Persian Gulf, and multiple Chinese ports.

1

Article Report on P&I claims involving vessels under pilotage 1999-2019

published on 22 December 2020

This report on incidents involving vessels under pilotage, is an update on that issued in 2006. The IG’s first report examined five years of data between 1999 and 2004.

1