‘City of Rotterdam’ Investigation MIAB Report

[sailorman]

Pilot error & the Master acted far too late

Pilot error resulting from ‘relative motion illusion’ has been identified as the likely cause of the collision between the vehicle carrier City of Rotterdam and a DFDS roll-on/roll-off passenger ferry on the River Humber in December 2015, the UK Marine Accident Investigation has determined.

http://gcaptain.com/error-due-to-re...dd-in-city-of-rotterdam-investigation-report/

 

[Minchsailor]

I spent some time yesterday reading this report. Easy in hindsight, but it seemed to me a disaster waiting to happen.

All navigating the C of R knew it was on the 'wrong' side of the channel soon after it entered it. It was blowing 40kns, the ship was in ballast and it was know she was a pig to handle in those conditions. Strong tide, it was known that the there can be a cross tide in the region of the Humber where the ship was.

Due to unusual design of the bridge it was again know that it was necessary to navigate from a central position, but the bridge was not equipped to do that (position of the VHF).

I guess like many of us here, I have a GPS repeater visible from the helm which gives me COG, as well as the compass to give heading. If they had used that that, they would have known in good time that the ship was not swinging to the south, and more helm/speed/power was needed. That could have given the Primula Seaways time to take avoiding action.

 

[alahol2]

Would a simple pleasure boat plotter not have given warning that they were on the wrong side of the channel? Even my old PDA plotter tells me I am in the small boat channel into Portsmouth harbour.

 

[prv]

Would a simple pleasure boat plotter not have given warning that they were on the wrong side of the channel?

Yes - and that they weren't facing in the direction that the pilot thought.

It is a little alarming that the third officer was drawing big confident crosses on the chart in completely the wrong place. How was he making those "fixes"?

Even my old PDA plotter tells me I am in the small boat channel into Portsmouth harbour.

Do you use the plotter for that, though? I would always be doing it by eye - exactly what caused the problem for this pilot.

(I can see which way my bow is pointing, though )

Pete

 

[status]

Slight thread drift.

Anyone else think of tubes of squeezy cheese whenever they read Primula Seaway?

 

[sailorman]

Yes - and that they weren't facing in the direction that the pilot thought.

It is a little alarming that the third officer was drawing big confident crosses on the chart in completely the wrong place. How was he making those "fixes"?



Do you use the plotter for that, though? I would always be doing it by eye - exactly what caused the problem for this pilot.

(I can see which way my bow is pointing, though )

Pete

Have you seen the Car transporters bow, more akin to a dirigible airship

 

[davidej]

Slight thread drift.

Anyone else think of tubes of squeezy cheese whenever they read Primula Seaway?

No.

I think if those little segments, wrapped up in silver paper which fitted into a wheel shaped cardboard box.

 

[prv]

Have you seen the Car transporters bow, more akin to a dirigible airship

Yes, that's the problem.

Apparently they've since welded some kind of pointer onto the tip of it which is visible from the bridge.

Pete

 

[prv]

Anyone else think of tubes of squeezy cheese whenever they read Primula Seaway?

Yes - or rather, the little pots of it (generally expired) found in ration packs in Cadets

Pete

 

[Uricanejack]

Slight thread drift.

Anyone else think of tubes of squeezy cheese whenever they read Primula Seaway?

Not until you mentioned it. Now I am and I'm feeling hungry.

 

[Uricanejack]

Would a simple pleasure boat plotter not have given warning that they were on the wrong side of the channel? Even my old PDA plotter tells me I am in the small boat channel into Portsmouth harbour.

Admittedly I haven't read the report yet. I will it looks like it might be interesting.
Even so I think you are hitting a nail firmly upon its head.
There are quite a few gadgets on the bridge might have clewed the Pilot in. If he had bothered to look. Or if anyone else had looked.
Pilots are funny things. Technically for advice only. Never actually in charge off or responsible for the ship. Except in the Panama Canal.
Usually they are not familiar with a ships equipment and while they might have general idea about its handling characteristics.

I can just imagine asking the OOW or Master why didn't you question the pilots advice? Hearing the answer. It looked odd but I thought he knew what he was doing.

 

[sailorman]

Another 2 River Pilots involved here
http://www.ybw.com/forums/showthrea...llision-Caused-by-%91Catalogue-of-Failures%92

I wonder if any are the same ones in both incidents

 

[Uricanejack]

I have read the report now and I still think he is hitting a nail firmly upon its head.

There are quite a few gadgets on the bridge might have clewed the Pilot in. If he had bothered to look. Or if anyone else had looked.
Pilots are funny things. Technically for advice only. Never actually in charge off or responsible for the ship. Except in the Panama Canal.
Usually they are not familiar with a ships equipment and while they might have general idea about its handling characteristics. They may not fully understand the way a particular ship handles.

Having read the report. I cant help but think "Bollocks".

I don't have the expertise to say this illusion doesn't exist. The MAIB did test which say it does. OK It exists Its a contributing factor no doubt.

like the guy said a Day skipper with a plotter would have noticed.

I suspect the Humber Pilots have made a big issue of the Bridge windows because they don't like the ship are not used to it and the MAIB has bought it hook line and sinker.

Funny the report mentions the existence (Its a requirement) of a Pilot Plug at the forward conning station.
In some areas Pilots Bring on their own portable plotters and plug them in to the ships "Pilot Plug" and get the feeds from the ship DGPS AIS ect.
Clue No 1 Funny No mention of this By MAIB. Perhaps the Humber Pilots don't use them? Perhaps They Should?

The Ship sailed with the starboard RADAR on Stand By. No RADAR VDR info because Starboard RADAR on Stand By. WTF. No mention in Findings WTF, No Mention in Recommendations WTF, way to drop the ball MAIB.

Clue No 2 for them. Recommend Proper use of RADAR includes turning F!@#$%^ RADAR on.

Clue No 3 VDR should include feeds from both RADARS and ECDIS ECS. Dhu.

Clue No 4 If you turn two RADARS on The OOW can use one and the Pilot can look at the other one.

Clue No 5 Pilot can ask OOW to set RADAR to a Range and set up he likes. and ask OOW to acquire targets for him.

Clue No 6 OOW may not be an expert on the area but he can maintain a plot and track targets or vessels and communicate this to Pilot and master.

This collision happened primarily due to the same reasons the two earlier collisions mentioned in the report happened. along with failure to properly use all the available means to keep a look out and determine a risk of collision. And some piss poor use of VHF.
Piss poor communication between the Pilot and Uncle Bulgaria and his Pilipino 3/0. Exacerbated by the Pilots not making proper use of the Nav aids available to him. RADAR and ECS.

Both of those have heading lines. Most have AIS GPS integrated. Most Kinds will show both the course steered and heading made good. All you have to do is look at it.

Collision avoidance by eyeball alone? Wot No Finding No recommendation. WTF?

VTS operates on Channels 12 14 & 15. Little or no use made of VTS by ether vessel.

The communication between vessels was on CH 13 an un monitored Channel WTF? Wot No Finding No Recommendation. WTF?

Clue No 7 make a recommendation all passing arrangements in a VTS area be on The VTS Channel so all other Vessels and the VTS operators know what arrangements are being made.

The MCA does not like VHF communication for collision avoidance. The MCA and MAIB need to get their head out their ass. In a VTS area A Pilot and a PEC Master familiar with the area Should be able to communicate effectively by VHF.

PROPER USE OF VHF COMMUNICATION BRIDGE TO BRIDGE ON THE VTS CHANNEL. COULD HAVE PREVENTED THIS COLISION.

At first sighting when the Squeezy Cheese boat was wondering about where the City of Rotterdam was going.

Shortly After when the Squeezy Cheese boat was concerned how far to the north the other vessel was.

After their brief call on Ch 13 when no immediate action was taken.

When the Master of the Squeezy Cheese Reduced speed. Good time to call the Pilot Pillock and forget about being Polite and hurting his

feelings. Ask Him Why the F!@# You can Still see his Green Light on your Starboard Side. Ask Is there a problem with the ship. Demand some F!@#$%^ sea room on your side of the Channel immediately. Or If he can't immediate compliance. Ask for a GREEN to GREEN and Get conformation.

PS. It is not just the windows any one who has a bit of experience conning a ship from the forward end can tell you it is extremely important to stand near the centerline or your perspective will change considerably by even a small movement to the side. Particularly if trying to asses risk of collision visually. Or your heading and position in a channel.
It is often difficult for a person to adjust to a forward bridge if they have spent most of their experience on Aft Bridge vessels.

 

[Uricanejack]

Another 2 River Pilots involved here
http://www.ybw.com/forums/showthrea...llision-Caused-by-%91Catalogue-of-Failures%92

I wonder if any are the same ones in both incidents

According to the report there are 120 Humber Pilots, And an unknown No of DFDS PEC Masters so although possible it would be quite a coincidence.

 

[lpdsn]

like the guy said a Day skipper with a plotter would have noticed.

If the third officer had been able to accurately plot a GPS position on a paper chart they'd've noticed. More than half the day skippers I've sailed with could do that (most of the time).

Don't buy your argument that VHF communication would've averted the collision. It was the expectation of a change of course communicated over VHF that removed all options from the ferry. Yes there were opportunities for some of it to have been done better but basically one vessel didn't do what they'd told another vessel they would do, once that became apparent enough to be challenged it was already too late.

I'm really impressed that the MAIB went beyond just pointing the finger at the guy who made the mistake. They seem to have taken it very seriously, interviewing officers and pilots who'd work on the City of Rotterdam or the sister ship, going aboard to witness pilotage into the Tyne, and arranging simulation sessions with other pilots.

 

[Uricanejack]

If the third officer had been able to accurately plot a GPS position on a paper chart they'd've noticed. More than half the day skippers I've sailed with could do that (most of the time).

Don't buy your argument that VHF communication would've averted the collision. It was the expectation of a change of course communicated over VHF that removed all options from the ferry. Yes there were opportunities for some of it to have been done better but basically one vessel didn't do what they'd told another vessel they would do, once that became apparent enough to be challenged it was already too late.

I'm really impressed that the MAIB went beyond just pointing the finger at the guy who made the mistake. They seem to have taken it very seriously, interviewing officers and pilots who'd work on the City of Rotterdam or the sister ship, going aboard to witness pilotage into the Tyne, and arranging simulation sessions with other pilots.

I agree with you about finger pointing, blaming the guy doesn't solve anything.

I didn't say would have. I said could have. It was a lost opportunity. Would it have worked? maybe not. Could it have worked? maybe.
More forceful intervention from VTS is mentioned. Which would be VHF communication.

The Pilots error put the Ferries Master in an extremely difficult situation. I would not envy the Ferries Master.
It was a narrow channel.
Ships pass close in narrow channels.
There is a very short time frame to asses a situation and react to it.
The Pilot told both the VTS operator and The Ferry he would take the expected course of action and then didn't.
The Ferry Master realised there was something not right but trusted the response from the Pilot.
The Ferries second officer made a simple error confirming port instead of starboard. This was not on VTS Channel. If on VTS Channel it is possible the VTS operator may have noticed. He couldn't on a channel he was not monitoring.

After this there was no further communication between the vessels.
The collision was not inevitable at this point.

The Ferry Master noticed the lack of action by the Pilot even though the had confirmed he was altering to the south.

The Ferry reduced speed. The Ferry was caught between a rock and a hard place at this point. The report points out altering to Starboard he would cross the oncoming ships bow or altering to Port The Ferry would be Altering to where the Pilot said he was going to alter. Dammed if you do Dammed if you Don't.

There was some attempts at last minute communication partly covered or interrupted by VTS which were to little and to late.

The MCA is very against ship to ship VHF communication to resolve risk of collision. Usually they are right. But in VTS Pilotage waters. the regular use of internship communication can improve arrangements.

 

[prv]

The communication between vessels was on CH 13 an un monitored Channel WTF?

It shouldn't be unmonitored, it's the GMDSS bridge-to-bridge safety channel.

Pete

 

[Uricanejack]

It shouldn't be unmonitored, it's the GMDSS bridge-to-bridge safety channel.

Pete

The CH 13 communication appears to have been recorded. The report does not say if recoded by VTS or VDR .
The report specifically mentions which VTS operators were monitoring which channels in this case 12, 14 & 15.
Chanel 13 is conspicuous by its absence.

The Ships had 2 Radios. one presumably on CH 16 one on VTS They changed to CH 13. Again the obvious conclusion is VTS and other Ships are not monitoring CH 13.

GMDSS Ch 13 may be more appropriate in a Non VTS area.

 

[Ceirwan]

The conclusions of the report for those interested:

SECTION 3 - CONCLUSIONS
3.1 SAFETY ISSUES DIRECTLY CONTRIBUTING TO THE ACCIDENT THAT
HAVE BEEN ADDRESSED OR RESULTED IN RECOMMENDATIONS
1. The collision stemmed from City of Rotterdam being set to the northern side of the
Bull Channel by the wind and the tidal stream followed by the distortion of its pilot’s
spatial awareness due to a ‘relative motion illusion’. [2.2]
2. City of Rotterdam’s pilot’s relative motion illusion deceived him into thinking that his
view from the window above the starboard VHF radio, which was 33° off the vessel’s
centreline axis, was the vessel’s direction of travel. [2.3]
3. As it was dark, the inward slope of the window removed all objects in the pilot's
periphery, and there were no visual clues such as a forward structure or bow tip, the
illusion would have been compelling. [2.3]
4. The pilot’s ability to reconcile the headings he had ordered with his perceived
direction of travel was probably hindered by further psychological effects of the
relative motion illusion, such as the cognitive costs of transferring between different
frames of reference. [2.3]
5. Soon after City of Rotterdam entered the main navigation channel, the master and
the third officer left the responsibility for the vessel’s safe passage predominantly to
the pilot. [2.4]
6. City of Rotterdam’s master and third officer did not challenge the pilot’s actions
despite concern at the vessel’s position being expressed by Primula Seaways and
the VTS. The master’s intervention, 14 seconds before the collision, was far too late
to be effective. [2.4]
7. City of Rotterdam’s bridge team’s over reliance on the pilot, and its lack of effective
monitoring of the vessel’s progress, were evidence of ineffective bridge resource
management. [2.4]
8. Although Primula Seaways’ engines were reduced to ‘half ahead’ 2 minutes before
the collision, a more substantial reduction of speed was warranted in view of the
doubt concerning City of Rotterdam’s movement. [2.5]
9. The VTS intervention at 2038 could have been more effective in alerting the bridge
teams on board both vessels to its concerns had it been prefixed with a ‘warning’
message marker and it had not referred to the pilot by name. [2.6]
10. The location of the VHF radios by the off-axis windows on board City of Rotterdam
increased the potential for relative motion illusion. [2.7]
11. The potential for relative motion illusion was unforeseen and therefore not taken into
account during the design of City of St Petersburg and City of Rotterdam. [2.7]
12. Stricter adherence to the ergonomic principles of bridge design detailed in SOLAS
V/15 would reduce the likelihood of human error. Therefore, the need for an IACS
UI on the interpretation of the ergonomic principles of bridge design warrants
reconsideration. [2.8]

 

[prv]

The CH 13 communication appears to have been recorded. The report does not say if recoded by VTS or VDR .
The report specifically mentions which VTS operators were monitoring which channels in this case 12, 14 & 15.
Chanel 13 is conspicuous by its absence.

The Ships had 2 Radios. one presumably on CH 16 one on VTS They changed to CH 13. Again the obvious conclusion is VTS and other Ships are not monitoring CH 13.

GMDSS Ch 13 may be more appropriate in a Non VTS area.

I've just gone and looked back at the report. As far as I can see it doesn't mention channel 13 at all

Pete