Why experienced crews still get caught out in routine entries
Contents
Use the links below to jump to any section:
- Why Pilotage Accidents Are Rarely About Skill
- Failure Pattern 1 – Over-Reliance on the Pilot
- Failure Pattern 2 – Silence on the Bridge
- Failure Pattern 3 – Speed Carried Too Long
- Failure Pattern 4 – Margins Assumed, Not Measured
- Failure Pattern 5 – Late or Absent Challenge
- Failure Pattern 6 – Tug and Thruster Overconfidence
- Failure Pattern 7 – Abort Options Left Too Late
- Why These Failures Repeat Across Ships and Ports
- Turning Accident Patterns into Barriers
1. Why Pilotage Accidents Are Rarely About Skill
Most pilotage and port-entry accidents involve:
- experienced pilots
- competent Masters
- certificated officers
- modern equipment
They do not involve ignorance of rules or lack of technical knowledge.
They occur because normalisation of routine erodes vigilance.
Familiarity replaces active verification — and margins quietly disappear.
2. Failure Pattern 1 – Over-Reliance on the Pilot
A recurring phrase in investigations is:
“The pilot was very experienced in this port.”
Experience is valuable — but it does not replace monitoring.
Over-reliance manifests as:
- Master disengagement
- bridge team silence
- assumptions about ship handling
- delayed intervention
When the pilot becomes the only active decision-maker, redundancy collapses.
3. Failure Pattern 2 – Silence on the Bridge
Many accident bridges were quiet.
No disagreement.
No confusion.
No raised voices.
Silence is often interpreted as professionalism — but in accidents, it usually means:
- nobody wanted to interrupt
- concerns were noticed but not voiced
- challenge felt socially awkward
Silence removes the final safety barrier.
A quiet bridge is safe only when everyone is actively monitoring.
4. Failure Pattern 3 – Speed Carried Too Long
Excess speed is one of the most consistent contributors to port accidents.
Common causes include:
- desire to “keep the schedule”
- belief that speed can always be reduced later
- confidence in tugs or thrusters
- late recognition of confinement
Speed is easy to carry and hard to remove.
Many accidents begin with the phrase:
“We were still slightly fast…”
5. Failure Pattern 4 – Margins Assumed, Not Measured
UKC, squat, and lateral margins are often known conceptually, but not tracked actively.
Failures include:
- relying on predicted values only
- not reassessing margins as conditions change
- ignoring interaction effects
- assuming “it’s always fine here”
Margins that exist only on paper disappear first.
6. Failure Pattern 5 – Late or Absent Challenge
In many cases:
- someone noticed the problem
- concern was internalised
- challenge was delayed
- intervention came after control was lost
Challenge is not ineffective — late challenge is.
Early, calm challenge prevents escalation.
Late challenge triggers confrontation.
7. Failure Pattern 6 – Tug and Thruster Overconfidence
Tugs and thrusters extend margins — but only within limits.
Accident patterns show:
- tugs engaged too late
- thrusters assumed to counter strong wind
- continuous thruster use masking loss of control
- reliance on assistance instead of geometry and speed
External force cannot correct poor fundamentals.
8. Failure Pattern 7 – Abort Options Left Too Late
Many investigations conclude:
“An abort was possible earlier in the manoeuvre.”
But aborts were not taken because:
- continuation felt easier than stopping
- nobody wanted to “cause delay”
- commitment was underestimated
- criteria were never defined
By the time an abort felt necessary, it was no longer possible.
9. Why These Failures Repeat Across Ships and Ports
These failures repeat because they are human, not technical.
They arise from:
- social pressure
- routine normalisation
- authority ambiguity
- optimism bias
- reluctance to disrupt
Different ships.
Different ports.
Same patterns.
This consistency is not depressing — it is useful.
Predictable failures can be designed against.
10. Turning Accident Patterns into Barriers
Professional operations turn lessons into barriers:
- explicit MPX
- defined speed gates
- assigned monitoring roles
- normalised early challenge
- predefined abort criteria
These are not signs of distrust.
They are signs of systematic professionalism.
Closing Perspective
Pilotage accidents rarely feel dramatic in the moment.
They feel routine — right up until the moment they aren’t.
The bridge teams involved were not careless.
They were quietly, gradually boxed in by eroding margins.
Learning from accidents is not about blame.
It is about recognising patterns early — and breaking them while options still exist.
Tags
pilotage accidents · port entry failures · bridge human factors · maritime safety · accident investigation · bridge operations