‘Cosco Busan’Setting the Scene

for Modernisation

Australasian Maritime Pilots Institute Workshop

Sydney23 October 2009

Acknowledgement Assistance from Captain John Cota

(‘Cosco Busan’ Pilot) and Captain Alex Amos in securing relevant court documents for this workshop.

Documents provided by Captain Cota to enable us in Australasia to learn the right lessons from the unfortunate accident.

Modernisation

Involves shift from the traditional ‘pilot centred’ approach to:

a proactive sophisticated human factors based ‘systems’ approach to safety in pilotage incorporating error management principles

application of available technology

Rationale Reduction in safety margins and increase

in risk through larger and larger ships being accepted to achieve greater efficiencies (refer next slide)

Ongoing development and availability of advanced technologies at lower and lower cost that have the potential to improve safety in pilotage (GPS, GLONASS, Electronic Charts, AIS, VDR, e-nav etc)

Similar situation in other ports

Rationale Availability of sophisticated safety management systems for

managing critical high risk tasks such as pilotage (Safety Case – Jens Rasmussen & James Reason Model; slides 7-11)

Expectation that sophisticated safety management systems will be applied in all high risk industries including shipping/pilotage

Very high cost of marine accidents- Sea Empress grounding (total liability of Milford Haven Port Authority $75 million)- SA Fortius in Port Kembla (claims close to $16 million)- Cosco Busan San Francisco (total claims close to $200 million)

Reason Swiss Cheese

ModelBasis of IMO Accident

Investigation Code & also widely used in other high

risk industries from Aviation to HealthCare

Reason Swiss Cheese Model

Defenses

Reason Model of Accident Causation

Organizational Factors

• Communications

• Management Structure

• Incompatible Goals

Local Factors

• Morale

• Fatigue

• Equipment

• Training

• BRM, Procedures, etc.

Active Failures

• Mistakes

• Slips

• Lapses

• Violations

Accidents

Organization Task/Environment IndividualsDefenses

Latent Failures

Were the actions asintended?

Unauthorizedsubstance?

Were consequencesas intended?

Sabotage,malevolent

damage,suicide. etc

Medicalcondition

Substance abuse

without mitigation

Substance abuse with mitigation

YesNoYes

YesNoYes

No No

Knowinglyviolating

safe operations

procedures?

Pass substitution

test?

Historyoff

unsafeacts?

Were procedures available, workable,

intelligible and correct

Possible reckless violation

System induced

error

Deficiencies selection &

training or in experience

Possible negligent

error

System induced

error

Blameless error but

corrective training or counseling indicated

Blameless error

Yes No

No

YesNo

Yes No

No Yes

Yes

Culpability Diagram James Reason

Rasmussen Human Performance Model

(Professional Dynamic Decision Making)

Situations

Routine

Trained-for problems

Novel Problems

Modes of Control

Conscious Mixed Automatic

Skill-Based

Rule-Based

Knowledge-based

Rationale Increasing demands and very high levels of accountability of

professionals. What were previously seen as errors of judgment increasingly being viewed as criminal negligence

Altered public perception of ‘acceptable risk’

Widespread awareness that major accidents in confined waters can cause severe threats not only to ships, crews and cargoes but also to the public, environment, property, and local and regional economies Zero tolerance for marine accidents but especially those that involve loss of life and/or environmental pollution manifested by the introduction of ‘strict liability’ criminal laws to shipping accidents

Criminalization of seafarers including pilots

Our Changing View of Environmental Pollution

The pilot boarded at 6am and proceeded towards the Rip. The fog was thick and the shoreline was obscured but the pilot hoped the fog would clear by the time the leading lights could be seen. Unfortunately the fog did not clear and the Petriana went aground on Portsea Back Beach at 7am.

Petriana, Port Phillip Bay, 28 November 1903

The strategy was to lighten the vessel by releasing the cargo of 1300 tons of oil into the sea. The spill was described as:

“a film of great beauty, radiating all the colours of the rainbow, spread from Sorrento Back Beach to Point Nepean”.The pilot had 20 years experience and was held in high esteem; nonetheless his certificate was suspended for 12 months for carelessly navigating a vessel to cause its stranding

Chris Wighton MSV

Protection of the environment An increasing public perception that protection and

preservation of the environment is an issue which is of crucial importance to the future of the human race

International bodies, governments and other public bodies are pushing through legislation* designed to achieve the objective of protecting the environment

A widely held belief that the introduction of ‘strict liability’ offences is necessary to achieve the objective despite the undesirable consequences for a particular industry such as shipping Source: SEA EMPRESS PROSECUTION by Nick Greensmith Partner, Clyde & Co London*Oil Pollution Act 1990 (OPA 90)

Protection of the Environment

“As the world’s population becomes more environmentally aware and sensitive, tolerance for marine accidents resulting in pollution of the seas and environs… becomes less and less. As a result and because of enormous popular demand and support, prosecution of pollution incidents and polluters, even innocent ones does not appear to offend anyone’s sensibilities, other than those in the maritime industry”

Michael G. Chalos

Traditional ‘Pilot Centred’ Approach

This approach has a good record but is not adequate to meet present day demands of safety

Safety depends upon unrealistic notion of ‘unvarying error proof’ performance by the pilot

Research and experience has shown that human error is inevitable – in the nature of things

‘Pilot centred’ approach is susceptible to ‘one person error’ accident

Traditional Pilot Centred Approach

Average of 2.6 errors on a Qantas flight - No accident because of ‘defences’ and ‘safeguards in depth’ against the inevitable human error. - Safety depends on human factors based ‘systems’ approach

Pressure on other high risk industries in Australia to adopt a similar approach to human error and safety

‘Single person error’ accident is no longer acceptable in any high risk industry in Australia and increasingly in other countries

The issue is not why an error occurred, but how it failed to be corrected

‘Cosco Busan’ ( 07 November 2007)

High Profile Pilotage Accident highlighting vulnerability of ‘pilot centred’ approach to ‘single person error’ accident and consequences

‘Cosco Busan’ allision with Bay Bridge

The container ship M/V Cosco Busan struck the Bay Bridge in San Francisco Bay at 08:30 on 07 November 2007. An approximate 100' gash in the hull of the vessel resulted, and 58,000 gallons (approx 200 tonnes) of fuel oil was released into the water.

Impact Governor of California, Mayors of Berkley

and San Francisco declared a state of emergency in the Bay Area

About 200 miles of coastline was affected by spill, 26 miles seriously contaminated

More than 1,854 birds of 45 species killed Large numbers of the public involved as

volunteers in the cleanup and rescue and rehabilitation of wildlife

San Francisco Bay Bridge Tower D

Container Ship ‘Cosco Busan’

Length 275m, Breadth 40m, Draft 12.20 m Crew 23

M/V COSCO BUSAN

Navigation Equipment- 3 cm Radar

- 10 cm Radar

- Electronic Chart System (ECS)

- Conning Information Display

- Automatic Identification System (AIS)

NTSB

NTSB

NTSB

NTSB

Relative Experience Pilot

- Bar Pilot for 27 years- A few thousand trips under the Bay Bridge- Not uncommon to operate in fog- Recurrent training for ship-handling in simulators and manned scale model vessels

Master- Master for 10 years- 2 weeks with company, vessel and crew- 1st time in San Francisco Harbour- 1st time under way on ‘Cosco Busan’ without company supervisors

Timeline

0620 Pilot on board, heavy fog 0810 Ship leaves berth 0820 In bar channel, turn to port 0822 Discussion about red triangles 0823 Turn to port 0826 Turn to starboard 0827 VTS contacts ship 0830 Allision with D Tower

NTS

NTSB

Track from undocking until impact - NTSB

NT

Ground track prior to collision - NTSB

Cosco Busan – Specific Charges

1. Clean Water Act – Negligent Discharge of a PollutantJOHN JOSEPH COTA,

did negligently cause the discharge of oil in such quantities as may be harmful from a vessel, the M/V Cosco Busan, into and upon the navigable waters of the United States, without a permit. Specifically, on or about November 7, 2007, Defendant Cota, while piloting the M/V Cosco Busan, caused approximately 58,000 gallons of heavy oil to be discharged from the vessel into San Francisco Bay by acting in a negligent manner, that included the following:

(a) failing to pilot a collision free course; (b) failing to adequately review with the Captain and crew of the

M/V Cosco Busan prior to departure the official navigational charts of the proposed course, the location of the San Francisco Bay aids to navigation, and the operation of the vessel's navigational equipment;

(c) departing port in heavy fog and then failing to proceed at a safe speed during the voyage despite limited visibility;

(d) failing to use the vessel's radar while making the final approach to the Bay Bridge;

(e) failing to use positional fixes during the voyage; and (f) failing to verify the vessel's position vis-à-vis other established

and recognized aids to navigation throughout the voyage. All in violation of Title 33, United States Code, Sections 13 19(c)(l)

(A) and 1321(b)(3), a Class A misdemeanor.

2. Migratory Bird Treaty Act

JOHN JOSEPH COTA,without being permitted to do so by regulation as required by law, did take migratory birds, including at least one Brown Pelican, (Pelecanus occidentalis), Marbled Murrelet, Brachyramphus marmoratus), and Western Grebe, (Aechmophorus occidentalis).All in violation of Title 16, United States Code, Sections 703 and 707(a), and Title 50, Code of Federal Regulations, Sections 21.1 1,20.71 and 20.72, a Class B misdemeanor.

CALIFORNIA BOARD OF PILOT COMMISSIONERS INVESTIGATION CITES PILOT ERROR IN COSCO

BUSAN ACCIDENT

October 23, 2008 The Board of Pilot Commissioners today issued a report of the investigation by its Incident Review Committee (“IRC”) of the accident on November 7, 2007.

The Board of Pilot Commissioners for the Bays of San Francisco, San Pablo and Suisun was established in 1850 to provide State oversight for the San Francisco bar pilots. The Commission licenses and regulates maritime pilots navigating San Francisco Bay and its tributaries as far inland as the Ports of Stockton and Sacramento, and In Monterey Bay. The Board's responsibilities include training, incident investigation and rate determination.

IRC – Report As a result of its investigation, the IRC concluded that pilot negligence was a factor in the accident. The IRC report summarized its conclusions as follows:

(1) Captain Cota failed to utilize all available resources to determine visibility conditions along his intended route when it was obvious that he would have to make the transit to sea in significantly reduced visibility;

(2) Captain Cota had exhibited significant concerns about the condition of the ship’s radar and a lack of familiarity with the ship’s electronic chart system, but failed to properly take those concerns into account in deciding to proceed;

(3) That, considering the circumstances of reduced visibility and what Captain Cota did and did not know about the ship and the conditions along his intended route, he failed to exercise sound judgment in deciding to get underway;

IRC – Report(4) Captain Cota failed to ensure that his plans for the transit

and how to deal with the conditions of reduced visibility had been clearly communicated and discussed with the master;

(5) Once underway, Captain Cota proceeded at an unsafe speed for the conditions of visibility;

(6) When Captain Cota began making his approach to the Bay Bridge, he noted further reduced visibility and then reportedly lost confidence with the ship’s radar. While he could have turned south to safe anchorage to await improved visibility or to determine what, if anything was wrong with the radar, Captain Cota failed to exercise sound judgment and instead continued on the intended transit of the M/V Cosco Busan, relying on an electronic chart system with which he was unfamiliar.

(7) Captain Cota failed to utilize all available resources to determine his position before committing the ship to its transit under the Bay Bridge.

Pilot Sentencing

17 July 2009

Sentence Pilot received sentence of 10 months

imprisonment for violating Clean Water Act and 6 months for violating Migratory Bird Act. (Both sentences to be served concurrently)

Two hundred hours of community service Judge imposed no fine because of financial

obligations and multiple civil suits faced by pilot Imprisonment to be followed by one year of

supervised release during which time pilot cannot serve as a pilot or ship captain.

Medical issues not taken into account in sentence

Pilots as environmental stewards

“Today’s guilty plea is a reminder that the Cosco Busan crash was not just an accident but a criminal act. This is not a case involving a mere mistake. The lesson here is that environmental stewards*, who abandon ship, act negligently and cause environmental damage will be vigorously prosecuted”John C Cruden, Acting Assistant Attorney General for Justice Department’s Environment and Natural Resources Division

* Steward in the biblical sense is someone who takes care of something. (Knowledge of environmental laws part of pilot licensing)

Alert to the Maritime Industry

“John Cota was an experienced pilot that was handsomely compensated for his special knowledge of ships and expertise in local waters. ...

This case should sound an alert to those in the maritime industry that safety rules and procedures are meant to be followed, safety equipment is meant to be used, and that those who act otherwise and despoil our natural wonders will be prosecuted to the full extent of the law” Joseph Russoniello U.S. Attorney for the Northern District of California

Plea Agreement

Cota admitted that he: Failed to adequately discuss the intended route through San

Francisco Bay with the Master or crew as is required; Failed to use the ship’s radar in the final approach to San Francisco

Bay Bridge; Failed to recognise two red triangles on the ships electronic chart

system that actually are the buoys marking the bridge tower; Failed to verify the meaning of the red triangles by using the ship’s

paper chart or radar: Failed to inform the crew of his method of navigation that he relied

on using a particular radar setting; and Failed to advise the crew of a radar beacon that marked the center

of the Delta Echo span

Pilot/Fleet Management - Civil Lawsuits

Class Action by 5 fishermen City of San Francisco State of California, Two individuals who claim that they were subsistence fishermen and it is

in the Calif. constitution that they have a constitutional right to fish, Fleet Management suing John Cota and San Francisco Bay Pilot’s

Association Continental Insurance 

(Continental Insurance is suing John Cota to return approx. $ 2,000,000 or more paid for his criminal defense. Since no pilot had ever been criminally charged prior to this event criminal defense was not included in the policy. The policy simply states "legal defense." Continental Insurance is claiming foul and wants John Cota to return money. )

Also on all but the suit against John Cota by Fleet Management he is named as a secondary defendant with Fleet Management.  

PLEA AGREEMENT

Fleet Management

Fleet Mgt. Ltd. Agrees to Pay $10 Million for Pollution and Obstruction Crimes

WASHINGTON 13 August 2009 — Fleet Management Ltd., pleaded guilty today to a criminal violation of the Oil Pollution Act of 1990 for its role in negligently causing the discharge of more than 50,000 gallons of fuel oil into San Francisco Bay from the Cosco Busan when the vessel struck the San Francisco Bay Bridge in dense fog on Nov. 7, 2007.

According to the factual statement signed by Fleet Management, the crew of the vessel:

Was not adequately familiar with certain ship-specific navigational equipment,

Did not engage in a berth-to-berth passage planning process or prepare written berth-to-berth passage plans,

Did not conduct an adequate Master – Pilot exchange of information, Did not fully utilize or operate the ship’s radar and electronic chart

system, and Did not take fixes during the voyage.

Fleet Plea Agreement

Criminal fines are $8 million plus another $2 million in community service payments to the Fish and Wildlife Fund for a total of $10 million.

Three Years Probation. During the term of probation Fleet will be subject to an

enhanced compliance program with a number of strict requirements for various audits

Guilty pleas part of a plea agreement with the government subject to approval by Judge Susan Illston of the U.S. District Court for the Northern District of California

Sentencing has been set for December 11 2009

Fleet Management Fleet admitted that after the ship hit the Bay Bridge, it

concealed ship records and created materially false, fictitious and forged documents with an intent to influence the Coast Guard’s investigation.

In particular, a false berth-to-berth passage plan for the day of the crash was created after the incident at the direction of shore-side supervisors known as superintendents and with the knowledge of the ship’s master.

Additionally, a ship officer falsified the ship’s official navigational chart to show fixes that were not actually recorded during the voyage.

Other records including false passage planning checklists were also created after the fact.

Industry StandardsUnder recent law reform mere compliance with industry standards may not be sufficient to avoid a conviction. The fact that a given practice is common within a particular industry is a relevant factor for consideration but does not of itself mean that observance of that practice cannot fall far below what can reasonably be expected. It will not be a defence if a jury is not impressed by the standards which the industry has set for itself.

Source: SEA EMPRESS PROSECUTION by Nick Greensmith, Partner, Clyde & Co London

Paradox for Laypersons Without any criminal intent John Cota

made an error of judgment. He is convicted of a strict liability offence and receives a jail sentence

Fleet management is only fined despite its superintendents and officers falsifying ships records etc with criminal intent

“This is a court of law young man, not a court of justice” - Oliver Wendell Holmes Jr

‘Cosco Busan’ Strict Liability

STRICT LIABILITY Generally to be guilty of a crime, a person

must act with ‘criminal intent’ For health and public welfare violations

‘strict liability’ applies such as an ‘accidental spill after a casualty’

Strict liability means that an individual can be found criminally liable without having had criminal intent in the traditional sense.

Strict liability offences carry heavy fines and jail sentences

SA Fortius – Section 410B

Decision 17 September 2004 Several points of law explored

- Negligence- Contract law- Invalid Pilots License- Trade Practices Act- Section 410B as being unconstitutional

SA Fortius – Section 410B Judge upheld ‘Statutory Immunity’ against

civil liability conferred by Section 410B against all arguments

Good commercial reasons for upholding Section 410B and not upsetting the delicate balance.

Judge’s task is to deal effectively with points of law. The court is assisted on technical matters by expert witnesses.

Technical matters seen as a secondary issue

SA Fortius – Section 410B Negligence decision based on ‘proximate cause’ Proximate cause – identified as failure to act by

the master when 150 metres off the berth Status quo maintained of pilot’s role in a ‘legal*’

sense as an adviser Use of ‘proximate cause’ based on a point of law

that is consistently applied in such situations Proximate cause approach the antithesis of a

‘root causes’ and safety management system approach

* To accommodate ‘statutory immunity’. Does it reflect reality?

‘SA Fortius’ Decision

“The decision shows once again (if there was any doubt) that judicial intervention is solely aimed at resolving issues of legal liability and is not an effective means for investigating accidents or human error with a view to improving safety management”

John McCoy Former President Marine Board of Victoria

‘Petriana’ (1903) to ‘Sea Empress’ (1996) and ‘Cosco Busan’ (2007

Consequence of public concern for the protection and preservation of the environment as expressed in legislation:

Duty of care is extended to public and third parties Not a consideration in the ‘Petriana’ case (1903) First applied in the ‘Sea Empress’ grounding in Milford

Haven 1996 Again applied in the ‘Cosco Busan’ case (2007)

What would the legal consequences have been if the ‘Cosco Busan’ struck the bridge without any oil spillage?

Pilotage Incident - Investigations Civil Liability – Fortius, Amarantos, Kourmala (Admiralty, Trade

Practices Act*) – Judgment based on ‘Balance of Probabilities’ Regulators (AMSA - Masters Certificate) – Prudent mariner test Pilotage Regulator (Pilot License) – Breach of Code for Pilot

Licensing and or Harbour Masters Directions and Codes of Practice ‘OOCL Sydney’

Criminal (Public Prosecutor) – Beyond Reasonable Doubt: ‘OOCL Sydney’

Safety Investigation [Australian Transport Safety Bureau (ATSB) or State equivalent Systems approach (No blame Safety Investigation)

Pollution – {Strict Liability – ‘Sea Empress’ (Milford Haven); ‘Cosco Busan’ (San Francisco)}

Others*Tug Kourmala collision with Pernas Arang off Hay Point on February 28, 1995. Ruling handed down on 19 April 2007 in Queensland Supreme Court. Section 74 of the Australian Trade Practices Act cited.

Food for thought

The late great US Coast Guard Captain Dominic Callicchio, who reformed American maritime

law…, theorised that so many maritime rules were created so that no rules were clear. This led to confusion in operation and policy but complete clarity in hindsight and prosecution.

 

Very Low Incidence of Accidents and Safety in

Pilotage Rarity of pilotage accidents shows limits of a statistical

approach in drawing meaningful conclusions with regard to safety

Captain John Cota over a 27 year career had a record of 99.78% safe pilotages. The statistics for the Inner Route Barrier Reef pilotage are close to 99.99%

Pilots cannot rely on statistics alone to prove they have been operating in a safe manner after an accident. The trend is to apply a ‘due diligence’ (‘duty of care’ or ‘standard of care’) test particularly if there is environmental pollution or loss of life.

Due Diligence

Where it is possible to guard against a foreseeable risk, which though perhaps not great, nevertheless cannot be called remote or fanciful, by adopting a means which involves little difficulty or expense, the failure to adopt such a means will in general be negligent

From Richard Robinson R2A

Due Diligence

“Risk and liability is now based on the very sensible ethical position of the common law, namely that all reasonably practical precautions are in place based on the balance of the risk versus the effort required”

Richard Robinson - Diligence Engineer R2A

Due Diligence and Cosco Busan The primary defence against negligence is ‘due diligence’.

This means that a reasonable person (in the eyes of a court) in the same position would have undertaken certain procedures and processes to ensure whatever it is that did happen, on the balance of probabilities should not have happened

What could have guarded against the risk of the accident occurring?

A Master/Pilot exchange (MPX) to develop a ‘shared mental model’ leading to a passage plan with contingencies and defined bottom lines and responsibilities (BRM)

What is the cost of conducting such a MPX?

A few minutes of time and the cost of the paper!

Expanded Notion of Due Diligence

Role of VTS Regulators Oversight

- Selection

- Training

- Medical Standards

- Operational Practices

- Competency checks Pilot Organization Tugs Port & Hydrographic Service

- Standard Passage Plans for ports

MEETING CONTEMPORARY BENCHMARKS IN ‘DUE DILIGENCE’ AND ‘STANDARD OF

CARE’

Modernisation

Modernisation – Implementation Issues

Involves shift from ‘pilot centred’ to a human factors based ‘systems’ approach

Shift to ‘systems’ approach implies radical change in ‘maritime culture’ in pilotage and particularly ‘professional culture’ of pilots based on the ‘traditional pilot centred’ approach

Maritime culture (legal, commercial, organizational & operational) in pilotage based on legal notion of the pilot as an independent professional person contracted to navigate the ship but in a civil liability sense considered an advisor providing local knowledge to the master

Immunity of Pilot & Employer

The civil immunity of the pilot and his/her employer withstood numerous challenges from 1913 onwards on the basis of ‘lending certainty to commercial dealings’ until the ‘Sea Empress’ grounding at Milford Haven on 15 February 1996 and ‘Cosco Busan’ 07 November 2007.

Both cases involve environmental pollution

Human Factors - Shipping

“There is probably no enterprise that could profit from the human factors consideration more than merchant shipping. The accident figures are incredible… The potential for CRM and other human factors areas to contribute to the alarming situation in the marine industry is great, but whether it will ever be realized is difficult to say. Safety standards in the marine world seem to be resistant to even the most potent forces: loss of life, loss of capital equipment and financial liability.”E.I. Wiener, B.G. Kanki and R.L. Helmreich (1993) Cockpit Resource Management Academic Press Pages (494-495)

Implementation – Robert Helmreich BRM is an unrealized concept in shipping Affects of culture (national, industry, professional and

organizational) on professional behaviour needs to be understood and acknowledged

Nature of errors in the normal operational environment need to be known.

Databases need to be built and maintained showing the nature and frequency of errors

Multiple strategies need to developed for managing error

Finally full implementation will require structured training using a high fidelity full mission bridge simulator

CLARIFICATION OF PILOTS ROLE

Modernisation

Traditional/Historical Justification for Pilot

Local knowledge National security Independent judgment (Seamen's Vade Mecum 1707)

Navigation expert needed in case masters judgment overwhelmed by commercial pressures*. Conforms with the latest ideas on risk management and Leader/follower model

Commercial Risk: 18th century Swedish East India ship carrying cargo equal in value to half the GDP of Sweden*(KLM/PANAM Accident 1977)

Vade Mecum 1707

The Duty of the Pilot…...8. No Masters of ships shall force Pilots to

pass through dangerous places, and to steer courses against their will; and in case of contrariety of opinions shall be governed by the advice of the most expert mariners

Modern Justification for Pilot Up to date knowledge of fairways and conditions Expert shiphandler* in port conditions Knowledge of regulations and by-laws Port/State/National Representative involved in

protection of port/public/state interests such as infrastructure and waterways

National Security Independent Judgement

Must work with bridge team but also exercise independent judgment if necessary. Leader/Follower model (BRM)

Expert in development & application of systems approach to safety in piloting conditions (BRM)

*Not recognized in Admiralty Law (‘SA Fortius’)

Pilot Joint Manager of High Risk Operation

Acknowledgement of pilot as joint manager of risk raises knowledge of human factors to prime importance. Requires development of ‘selection criteria’ and proper training in:

Shiphandling (manned model, on the job and simulator based) using a competency based approach

Passage planning (Piloting to a passage plan) Application of modern technology (Instrument

piloting) Application of error management (BRM) principles and

techniques in pilotage

All above highlighted in the ‘Cosco Busan’ incident

In addition to local knowledge

Traditional Pilot Training

- Total emphasis on local knowledge- Licensing based entirely on visual piloting- On the job training- Time based or number of trips

Not adequate to meet present day demands of safety

Until recently no testing for aptitude, requirement for simulator training, professional development etc

Modernisation – Pilotage

Hardware Software(People)

Materials, Design,Machinery, Equipment,

(Portable Piloting Unit) etc.Human Factors

Safety Culture‘Holy Grail’

Selection and Training

Safety ManagementSystem

(Organization, Proactive, Reporting)

Individual Technical Skills and Experience

ResourceManagement

Modernisation - Australia

Modernisation (systems approach) an Australasian Maritime Pilots Institute (AMPI) initiative in 2002

Australia leading in understanding the need for modernisation in pilotage. Understanding has now achieved critical mass

Blueprint has been developed and is in various stages of implementation in Australia with Queensland leading

AMPI - VisionPiloting within a BRM framework to a passage plan with a reserve of practiced and regularly validated skills to deal with abnormal and emergency situations

‘Truly superior pilots are those who use their superior judgment to avoid those situations where they might have to use their superior skills’

Recent Initiatives Development and implementation of Pilotage Safety

Management Systems (PSMS) including pilotage operating procedures :

- Consensus on good practice

- Guidelines where consensus not possible

- Piloting to a passage plan

- Procedures for communication

- ‘Optimum speed’ and ‘track’ Pilots role defined in modern terms Development and implementation of ‘No blame reporting

system’

Recent Initiatives - 2 Professional development (Advanced Marine

Pilots Training Course) Human Factors (HF) Initiatives Use of Portable Piloting Units and Instrument

Piloting Course 2nd Generation BRM Course Development of ‘Shiphandling Questionnaire’

based on standard texts to establish baseline of hydrodynamic knowledge

Manned Model Training in early stage of training to consolidate technical knowledge and skills

Recent Initiatives - 3

Development of ‘Pilot Competence and Performance Guide’ by AMPI

‘It works for me therefore it is right’ being replaced by an approach based on hydrodynamic principles and risk management

Structured simulator training based on a Competency Based approach for normal, abnormal and emergency situations

Competency Audits incorporating technical skills

Finally A number of issues have emerged which are

having a major impact on critical aspects of pilotage

It is best for pilots & regulators to understand the issues

Addressing the issues requires a reappraisal of several aspects of pilotage (Legal framework, pilots role, selection, training, operational practices, use of technology, development and implementation of a proper human factors based safety management system etc.)

New Realities

‘Cosco Busan’, ‘OOCL Sydney’ and other such incidents show that we are now faced with new realities for which there are no ready made solutions. We need to continue to seek, find, develop, and implement solutions appropriate to today’s needs

FinallyPilotage is located at a strategic point in the shipping industry. With the right mindset pilots are in a position to provide the leadership in helping the shipping industry in understanding and properly implementing a systems approach

ENDThank You

Ravi NijjerPrincipal Consultant

Marine Consultancy Group Pty LtdTel: + 03 9830 0649

Mobile: + 0419 565 860ravi.nijjer@marcon.com.au