201947 Wrong helm order causes crash

Edited from NTSB DCA16FM003

A specialised heavy-lift cargo vessel with wheelhouse and accommodation forward was inbound under pilotage. The Master, an OOW and a helmsman were also on the bridge. After the first course change under the con of the pilot, he commented that the vessel seemed hard to handle. The Master replied that the vessel was normally quite responsive. The pilot conceded that few vessels like this one, with wheelhouse forward, visited the port. He asked the bridge team to let him know if he oversteered or otherwise did anything they considered out of the ordinary, considering his lack of practice with this type of ship.

As they met an outbound vessel the pilot and Master went to the port bridge wing to monitor their proximity to a berthed ship on their port side. Looking aft, the pilot thought their stern would come too close to the berthed vessel. Wishing to swing the stern away, he ordered increasing amounts of starboard helm in quick succession.

The orders were executed, but the starboard helm actually brought their stern close in on the berthed vessel. In looking aft, the pilot had given the wrong helm order and the bridge team had not reacted or otherwise caught the error. The stern nonetheless cleared the berthed vessel, but by now the swing to starboard was very rapid. Notwithstanding emergency manoeuvres, the vessel crossed the 245 metres of the channel and struck some barges on the opposite bank.

 

Lessons learned

• The bridge team was unaware of the pilot’s intention to move the stern away from the berthed vessel. Had they known what he intended, the error may have been caught in time. ‘Thinking out loud’ before acting is one way for a pilot to communicate their intentions and giving the bridge team a chance to provide input.
• Early indications of the pilot’s unease with a wheelhouse forward design should have warned the Master that extra risk mitigation measures would be needed.