The marine industry is unusual in that up to five people have to coordinate their movements and actions to manoeuvre a massive floating object safely to berth. Working as individuals, each in their own bubble, is a recipe for failure, as was the case in a recent Mars Report, in which a cruise ship hit a berth while mooring.

The Mars reports are compiled (anonymously) by The Nautical Institute to prevent other accidents from happening. A summary of the incident:

In the early morning hours, a passenger vessel was inbound for the port with an arrival pilot at the con. There was a significant ebb tide setting at about 2.3 knots, so a docking pilot and assisting tug had been ordered. The docking pilot boarded and had a discussion with the master about the docking manoeuvre. Shortly after this, the docking pilot took the con from the arrival pilot.

The bridge team included the master, staff captain, an officer, a cadet, a lookout and a helmsman. Additionally, an officer was stationed at the forward mooring platforms, port and starboard, to relay distances to berths A and B (see diagram below). About 15 metres separated the two platforms and the officer alternated from one to the other as needed.

The tug was positioned on the starboard side, without lines, to act as a pivot point for the starboard turn into berth A. The pilot gave helm and thruster orders and the master complied using a controller. With the vessel’s speed at about 1.4 knots, the bow began approaching berth B. The officer forward gave a warning. The bow soon made contact with berth B, causing significant damage to two levels of the shoreside vehicle parking area.

Investigation findings

The official investigation found, among other things, that:

  • Minimum safe distances had not been set out during the docking discussions, so there was no shared mental model of where the threshold was.
  • There was little evidence of the bridge team practising the technique of “thinking aloud” that would have allowed for verbally sharing the mental model of the current and future situations.
  • Members of the ship’s bridge team were not engaged effectively in helping the pilot and master execute the manoeuvre.
  • The officer at the forward mooring platforms had no view of the tip of the bow, which made contact with the parking structure. Also, he was doing double duty alternating from port to starboard, which reduced his effectiveness.

Advice from The Nautical Institute

Since up to five people have to coordinate in order to manoeuvre a massive floating object safely to berth, working as a true team is paramount. Since human error is understood to be the most prevalent contributory factor to accidents, these situations call for strict protocols and procedural integrity.

Mars Reports

This accident was covered in the Mars Reports, originally published as Mars 202015, that are part of Report Number 329. A selection of this Report has also been published in SWZ|Maritime’s April issue. The Nautical Institute compiles these reports to help prevent maritime accidents. That is why they are also published on SWZ|Maritime’s website.

More reports are needed to keep the scheme interesting and informative. All reports are read only by the Mars coordinator and are treated in the strictest confidence. To submit a report, please use the Mars report form.