Lessons learned: Even local experts, like a pilot, can make mistakes

IThe docking plan had been discussed. With the help of two tugs, the ship was to turn 180 degrees from the quay and anchor on the port side.

When the ship was already out of the dock and almost stopped, it began to turn to port with the help of two tugs, as planned. The bow tug was pushing the bow to port and the stern tug was pulling the stern to starboard. During the maneuver, the officer at the aft mooring station reported to the bridge that the distance between the ship and the dolphin was now about 15 meters and decreasing steadily. The pilot immediately ordered the rudder to turn to port and gave several orders to the engines in quick succession, including full speed, full speed, half speed, half speed, and finally full speed, in addition to the rudder order. About two minutes after the pilot began giving the forward running orders, a muffled noise was heard aft. The ship was subsequently safely moored.

An underwater inspection later revealed no damage to the dolphins, but the sand around the dolphins’ base was slightly disturbed.
The ship’s rudder was found to be deflected about eleven degrees to starboard, probably due to contact with the bottom. The rudder stock was later found to be fractured. Repairs required dry-docking the ship, including the installation of a new stock. The ship was out of service for over two months.

The incident investigation determined that the pilot had misjudged the current. At the time, the pilot allegedly considered the current to be moving away from the berth (in a westerly direction), but in fact the current was heading towards him. The investigation also concluded that the pilot was essentially working alone during the berthing manoeuvre, indicating a failure in bridge resource management (BRM).