The 17,859 teu ultra large container vessel Vasco de Gama ran aground as it approached Port of Southampton in the early hours of 22 August 2016. Credit: Maritime Photographic
In the early hours of 22 August 2016, ultra-large container vessel (ULCV) Vasco de Gama approached Port of Southampton. The 339 m long, 17,859 teu vessel was the largest UK-flagged ULCV at the time and had two of the port’s specialist container ship pilots on board.
Despite the expertise of the two pilots and the bridge team, the ship ran aground on the western side of the Thorn Channel as it approached the port. An investigation into the incident revealed issues with human error when operating such large vessels in restricted waterways, which exacerbated the dangers of working within “reduced margins of operational safety”.
Luckily the case of Vasco de Gama was not serious and a combination of tugs and the ship’s engines enabled it to be refloated soon after grounding. But it reveals that proper planning and monitoring during navigation of the passage are vital to avoid similar safety problems.
The Vasco de Gama incident has prompted a wider study by the UK’s Marine Accident Investigation Branch (MAIB) of the safety risks of the increasing size of vessels within restricted waterways. Its focus is human factors and use of modern electronic navigation aids.
Steve Clinch, chief inspector for the MAIB, told SAS that how crew and pilot interacted on the Vasco de Gama has raised some important issues around human factors that apply to all bridge teams and pilots operating vessels, but which become even more vital when dealing with the reduced safety margins while operating a ULCV. This included the lack of a detailed plan, leading to an absence of shared understanding of the pilot’s intentions when passing other vessels or making the critical turns during the passage, and that the standards of navigation, communication, and use of the electronic charting aids on board were not up to scratch.
A closer look at these kinds of risk is important, as we are going to see a rise in ULCV numbers in the coming years, and so greater traffic in restricted waterways. At present there are 372 ULCVs, with capacities of between 10,000 and 17,999 teu, making up 17% of the global fleet, according to IHS Markit data. However, this is set to rise, with 10 ULCVs constructed in 2017, 54 this year, and a further 20 to be built by 2020.
Don Cockerill, secretary-general at the UK Maritime Pilots Association, said that in the United Kingdom, as in most parts of the world, there was a “continual increase” in ULCVs coming into service. He told SAS the challenges pilots face is that the ports are not getting any bigger, apart from “perhaps a bit of dredging”, so it is akin to “squeezing a quart into a pint pot”.
He added that more special attention and preparations had been given to preparing ports for very large crude carriers (VLCCs) and “one wonders if there is less fuss because it is container ship rather than a VLCC”.
Lessons from Vasco de Gama
The grounding of Vasco de Gama revealed what Clinch said was a “perennial problem with the lack of integration of ships team and pilots when handling large ships”. He said this must improve as, with the squeezed margins of safety, planning is of utmost importance. “All ports plan. They do a lot of work beforehand to check a vessel can get into port but when the ships come into port that plan has to be put in place properly,” he said. “In the Vasco de Gama incident report we found a degree of complacency between pilots in extending that plan to the bridge team.”
Without discussion of the plan before they came into the port, there was no “shared mental model”, so when things went wrong, people likely felt less able to speak up to question the pilot's decisions. There was a second pilot on board, common on larger vessels, but he did not step in either to challenge the first pilot.
The case highlights the importance of bridge teams first ensuring they are fully briefed as to the pilot’s plans, but also that they should speak up and use their own expertise if they can see an incident is likely to occur. Clinch suggested that, as larger ships are on predictable voyages and there is a lot of time to prepare, pilots send their plan to the vessel before it gets to port so the route can be set up on the electronic chart display and information system (ECDIS), “rather than just wing it on the day”.
Traffic management was raised as another issue that led to the grounding of Vasco de Gama, according to the MAIB report. Another vessel was allowed to transit the Thorne Channel while it was still travelling through, meaning Vasco de Gama was pushed further north and did not have as much sea room to make a turn. Despite acknowledging this and stating to the master that they would go deeper, the pilot did not drop farther south.
However, Cockerill told SAS it was likely that human factors were not the only issues that led to the grounding. “The big difference now is that the magnitude of forces involved with big ships is such that if something goes awry in the design criteria of the propellers, or the size of the rudder or other equipment, the repercussions are huge.”
He added that windage is "an obvious issue” on such large structures as ULCVs, particularly on the leeward side. “There are also issues underwater, not just with depth, but when moving in a tideway or contending with river current the forces are phenomenal,” said Cockerill. “Moving at just a couple knots on a 250 m ship there are big forces, but up to 400 m the forces are absolutely huge.”
What Clinch and Cockerill agree on is that more frequent refresher training on bridge resource management is needed for pilots, just as crew are expected to refresh their safety training as outlined in the STCW Convention 2010.
Cockerill said that far too often pilots come across “less than satisfactory bridge teams, which can end up making pilots too insular and rely on their own skill set”. This lack of communication and management can lead to a pilot missing key safety issues and ignore a bridge team’s expertise. Clinch said that while pilots were all extremely well trained and go through intense training schemes, they are likely to go through bridge resource management training only once.
Cockerill agreed that while pilots received a great deal of initial training for ULCVs, particularly in simulators, continual training is a must. He used the aviation sector as an example, stating that once pilots are trained to fly an A380 they must still go through refresher courses, ensure they have not developed bad habits, and are taught new techniques that have evolved over time. The same should be true for pilots globally, Cockerill said, but this does not currently exist in UK pilotage. He stressed that bridge management training should mimic the Australian marine pilots who not only do regular refresher course but also enhance the level of training each time.
"The dynamics of big vessels are unlike anything we’ve seen before when it comes to manoeuvring,” Cockerill said. What is clear is that as more ULCVs enter service, pilots and crew must ensure they are on top of their game in restricted waterways, with communication, planning, and training key to avoiding incidents.
MAIB launches review into ECDIS
The UK MAIB has seen a number of accidents involving ECDIS and found that it was a contributing factor in the grounding of Vasco de Gama.
The report said that neither the ship’s ECDIS nor the pilot’s portable pilot unit functionality was “fully utilised” and resulted in each system not providing adequate cross checks or alarms.
Clinch told SAS there was a concern that ECDIS was not being used in the way the manufacturers and regulations expected, despite crew being trained on the systems, as they are not intuitive to use. “The features to improve safety are buried under several layers and there are often a lot of alarms, which crew may switch off.”
In a two-year study, to be carried out in collaboration with the Danish maritime accident investigation branch, investigators will go on board 20 ships and watch “without judgement” to see how navigators use the equipment and ask why they are using it in that way. They will then analyse the results with academics specialising in the human element.
“Future design needs to be centred around humans rather than standards. An iPad is easy to use and intuitive. That is how electronic navigation aids should be,” said Clinch. He added that ECDIS design should go beyond the idea of a standard mode for ECDIS, where a default display could be brought up at the press of a button. He stressed this still would not solve the issue of vital safety features being accessible in an intuitive way.
The aim is to present a paper to the International Maritime Organization with recommendations to manufacturers on how to create human-centred ECDIS.