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UK MAIB Investigation: Pilot Fatigue Caused Ship to Contact in Thames

UK MAIB Investigation: Pilot Fatigue Caused Ship to Contact in Thames

The UK’s Marine Accident Investigation Agency (MAIB) has published the report of its investigation into the incident involving the chemical tanker Ali Ka and Oikos Jetty 2 on the River Thames near Canvey Island, England, on 25 October 2022.

Incident

ABOUTn 25 October 2022, the 129.5 metre oil and chemical tanker Ali Ka sailed from the Oikos fuel depot on Canvey Island, Essex, in the early hours of this morning. While manoeuvring away from the quay under the pilot, control of the vessel was lost and the vessel made contact with another fuel quay at that location. The accident damaged the starboard stern section of the Ali Ka, but no one was injured. As a result of the damage to the westerly most dolphin and the walkway at Oikos 2 quay, the quay was taken out of service for two months before being returned to service at reduced capacity until repairs were completed in September 2023. The investigation concluded that there was a strong possibility that the pilot was tired, unfamiliar with the quay and decided to sail without the support of a tug. It also found:

  • The Port of London Authority’s documentation on the use of tugs has not been comprehensively updated to include the mandatory presence of tugs at Oikos Quay, which is subject to the Control of Major Accident Hazard Regulations 2015.
  • The roles and responsibilities of Ali Ka’s navigation team were not separated in a way that would provide the pilot with the best possible support during the maneuver.
  • The pre-departure information exchange between the captain and pilot proved ineffective and unsuccessful, and the decision-making issues did not result in any changes to the departure plan.
  • The Port of London Authority’s maritime safety management system lacked transparency and pilot fatigue management did not address the identification and control of fatigue risks.
  • The Port of London Authority had learned lessons from previous incidents but these did not lead to a full update of procedures and the opportunity to use this knowledge was lost.
British MAIB investigation
Source: UK MAIB
How fatigue affects decision-making

Based on the pilot’s sleep, wakefulness, and work history, it is highly probable that the pilot was experiencing elevated levels of fatigue, and the mean predicted SAFTEFAST scores were within the ranges classified as high or severe fatigue at the time of the accident. Behaviors and performance changes consistent with fatigue were further examined using on-board transcripts and data collected during Critical Decision Making (CDM) interviews.

When individuals experience sleep loss and increased fatigue, common changes in behavior and performance occur due to the impact of sleep deprivation. Review of the on-board transcript revealed the following changes in behavior and performance consistent with fatigue:

  • Tunnel vision focused on water depth and distance from Oikos 1 pier, while simultaneously observing the proximity of Oikos 2 dolphin.
  • The conversations were one-dimensional, focusing on plan, time, and tide levels.
  • Potentially reduced risk perception related to the assistance the tug can provide and its balance, in the face of risks associated with decreasing water levels.
  • Reduced clarity of communication.
  • Short and sudden interactions with others, mainly with the Master.
  • Possible forgetfulness, e.g. failure to cancel a radio channel, which may result in missed calls to VTS.

While these behaviors are consistent with fatigue, other factors, such as the pilot’s personality, stress, or lack of recent experience in the role, may also contribute. However, fatigue exacerbates predispositions to problems such as poor communication and impairs the ability to regulate behavior.

From the CDM interview and the summary of the MAIB VDR review, additional behaviours consistent with fatigue were observed, including:

  • Delayed responses from pilot on bridge.
  • Possible loss of situational awareness regarding the position of the Oikos 2 dolphin, combined with incomplete sharing of the mental model with the Master.
  • Focus on tide level and time of day.

These results highlight the significant impact of fatigue on decision-making and operational safety, drawing attention to the need for effective fatigue management strategies in maritime operations.

Key findings regarding safety issues include:
  • Control of Ali Ka was lost, leading to contact with Oikos 2, because the departure maneuver plan was missing key information and was plagued by inconsistencies in PLA documentation.

  • BRM and Ali Ka’s training did not lead to the captain or the staging team effectively challenging the pilot’s plan.

  • The PLA’s detention procedure proved ineffective in dealing with clear challenges to the plan and did not help prevent this accident.

  • Previous accidents were not treated as warnings and risk controls were not reassessed in time to enable appropriate solutions to be implemented in the case of the Ali Ka, for example the provision of a tug.

  • The PLA’s management of pilots in terms of assignment and monitoring did not ensure adequate control of fatigue risk.

  • The PLA and Oikos Storage Limited risk management processes failed to mitigate the risk of contact with onshore infrastructure at Oikos 2, a COMAH facility.

  • The suboptimal calculation and presentation of the safety contour values ​​in ECDIS exposed everyone to an underestimated risk. This lack of appreciation of the risk by the ship’s bridge team meant that Pilot A was not well supported during the egress manoeuvres.

  • The pilot voyage plan did not provide for the Ali Ka’s safe departure from port.

  • Elements of the PLA’s maritime SMS system were not up-to-date, difficult to access, and in some cases contradictory, which did not facilitate the creation of a pilot’s safe flight plan.

  • The PLA leadership has learned safety lessons from previous accidents as well as from navigational risk assessments, but these lessons have not been fully embedded and have not led to lasting improvements in the PLA’s maritime SMS system.

  • The MPX checklists contained in the ICS Bridge Procedures Manual do not include the roles and responsibilities of bridge teams.