201950 Incorrect helm application goes unnoticed

29 Jul 2019 MARS 2019

As edited from NTSB (USA) report DCA16FM032


A loaded bulk carrier was outbound under pilotage with an OOW and helmsman on the bridge. The Master was present on the bridge from time to time but was not integrated with the navigation team. At one point, the pilot reduced the ship’s speed so the wake would not affect some nearby berthed wood-chip barges. He did not inform the OOW of the reason for the reduction. He then contacted the pilot of an inbound vessel by mobile phone to arrange a starboard-to-starboard meeting as this was more appropriate for their loaded condition and the depths available in the narrow ship channel. He did not inform the bridge team about this arrangement, nor did the team ask any questions.

Because the speed reduction had reduced the rudder’s effectiveness, at one point the pilot ordered hard port rudder and full ahead. The Master had just returned to the bridge and the pilot informed him of the starboard-to-starboard meeting. Some 26 seconds later the pilot ordered midship and then starboard 20. The helmsman confirmed this verbally, but unintentionally put the helm to port 20 instead of starboard 20. This error went unnoticed by the rest of the bridge team.

The pilot ordered hard to starboard. The helmsman started to put on more port helm before realising his error. He then put on full starboard helm. Both the pilot and the Master went to the port bridge wing to view
the port aft section. The vessel passed within one metre of the docked barges, but did not strike them.

However, the vessel scraped the rocky bottom near the wood-chip dock. There was water ingress in two tanks.

 

Lessons learned

  • During pilotage, incorrect helm application or incorrect helm order are two errors that are easily made. Bridge teams should always employ closed-loop communications but also visually counter-verify orders and executions as a matter of course.
  • Good BRM means keeping the team in the loop.