‘Cosco Busan’
Setting the Scene for
Modernisation
Australasian Maritime Pilots
Institute Workshop
Sydney
23 October 2009
Acknowledgement
Assistance from Captain John Cota
(‘Cosco Busan’ Pilot) and Captain
Alex Amos in securing relevant court
documents for this workshop.
 Documents provided by Captain Cota
to enable us in Australasia to learn
the right lessons from the unfortunate
accident.

Modernisation
Involves shift from the traditional
‘pilot centred’ approach to:
 a proactive sophisticated human
factors based ‘systems’ approach
to safety in pilotage incorporating
error management principles
 application of available technology
Rationale

Reduction in safety margins and increase
in risk through larger and larger ships
being accepted to achieve greater
efficiencies (refer next slide)

Ongoing development and availability of
advanced technologies at lower and lower
cost that have the potential to improve safety
in pilotage (GPS, GLONASS, Electronic
Charts, AIS, VDR, e-nav etc)
Similar situation in other ports
Rationale

Availability of sophisticated safety management systems for
managing critical high risk tasks such as pilotage (Safety Case
– Jens Rasmussen & James Reason Model; slides 7-11)

Expectation that sophisticated safety management systems
will be applied in all high risk industries including
shipping/pilotage

Very high cost of marine accidents
- Sea Empress grounding (total liability of Milford Haven Port
Authority $75 million)
- SA Fortius in Port Kembla (claims close to $16 million)
- Cosco Busan San Francisco (total claims close to $200
million)
Reason
Swiss Cheese Model
Basis of IMO Accident
Investigation Code & also widely
used in other high risk industries
from Aviation to HealthCare
Reason Swiss Cheese Model
Defenses
Reason Model of Accident Causation
Organization
Organizational
Factors
•Communications
•Management Structure
•Incompatible Goals
Task/Environment
Local Factors
•Morale
•Fatigue
•Equipment
•Training
•BRM, Procedures, etc.
Latent Failures
Individuals
Defenses
Active Failures
•Mistakes
•Slips
•Lapses
•Violations
Accidents
Were the
actions as
intended?
No
Unauthorized
substance?
No
Knowingly
violating
safe
operations
procedures?
No
Pass
substitution
test?
Yes
History
off
unsafe
acts?
No
No
Yes
Yes
Yes
Were
consequences
as intended?
Medical
condition
No
Yes
Were procedures
available,
workable,
intelligible and
correct
Yes
Sabotage,
malevolent
damage,
suicide. etc
Substance
abuse
without
mitigation
Substance
abuse with
mitigation
No
No
Yes
Possible
reckless
violation
Deficiencies
selection &
training or in
experience
System
induced
error
Possible
negligent
error
Yes
System
induced
error
Yes
Blameless
error but
corrective
training or
counseling
indicated
No
Blameless
error
Culpability Diagram
James Reason
Rasmussen Human Performance Model
(Professional Dynamic Decision Making)
Modes of Control
Situations
Conscious
Mixed
Automatic
Routine
Skill-Based
Trained-for
problems
Novel
Problems
Rule-Based
Knowledge-based
Rationale

Increasing demands and very high levels of accountability of
professionals. What were previously seen as errors of
judgment increasingly being viewed as criminal negligence

Altered public perception of ‘acceptable risk’

Widespread awareness that major accidents in confined
waters can cause severe threats not only to ships, crews
and cargoes but also to the public, environment, property,
and local and regional economies
Zero tolerance for marine accidents but especially
those that involve loss of life and/or environmental
pollution manifested by the introduction of ‘strict
liability’ criminal laws to shipping accidents

Criminalization of seafarers including pilots
Our Changing View of Environmental Pollution
Petriana, Port Phillip Bay, 28 November 1903
The pilot boarded at 6am and proceeded towards the Rip. The
fog was thick and the shoreline was obscured but the pilot
hoped the fog would clear by the time the leading lights could
be seen. Unfortunately the fog did not clear and the Petriana
went aground on Portsea Back Beach at 7am.
The strategy was to lighten the vessel by releasing the cargo
of 1300 tons of oil into the sea. The spill was described as:
“a film of great beauty, radiating all the colours
of the rainbow, spread from Sorrento Back Beach
to Point Nepean”.
The pilot had 20 years experience and was held in high
esteem; nonetheless his certificate was suspended for 12
months for carelessly navigating a vessel to cause its stranding
Chris Wighton MSV
Protection of the environment
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An increasing public perception that protection and
preservation of the environment is an issue which is of
crucial importance to the future of the human race
International bodies, governments and other public bodies
are pushing through legislation* designed to achieve the
objective of protecting the environment
A widely held belief that the introduction of ‘strict liability’
offences is necessary to achieve the objective despite the
undesirable consequences for a particular industry such
as shipping
Source: SEA EMPRESS PROSECUTION by Nick
Greensmith Partner, Clyde & Co London
*Oil Pollution Act 1990 (OPA 90)
Protection of the Environment
“As the world’s population becomes more
environmentally
aware
and
sensitive,
tolerance for marine accidents resulting in
pollution of the seas and environs…
becomes less and less. As a result and
because of enormous popular demand and
support, prosecution of pollution incidents
and polluters, even innocent ones does not
appear to offend anyone’s sensibilities, other
than those in the maritime industry”
Michael G. Chalos
Traditional ‘Pilot Centred’
Approach
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This approach has a good record but is not
adequate to meet present day demands of
safety
Safety depends upon unrealistic notion of
‘unvarying error proof’ performance by the pilot
Research and experience has shown that
human error is inevitable – in the nature of
things
‘Pilot centred’ approach is susceptible to ‘one
person error’ accident
Traditional Pilot Centred
Approach

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Average of 2.6 errors on a Qantas flight
- No accident because of ‘defences’ and ‘safeguards
in depth’ against the inevitable human error.
- Safety depends on human factors based ‘systems’
approach
Pressure on other high risk industries in Australia to
adopt a similar approach to human error and safety
‘Single person error’ accident is no longer acceptable in
any high risk industry in Australia and increasingly in
other countries
The issue is not why an error occurred, but
how it failed to be corrected
‘Cosco Busan’
( 07 November 2007)
High Profile Pilotage Accident highlighting
vulnerability of ‘pilot centred’ approach to
‘single person error’ accident and consequences
‘Cosco Busan’ allision with Bay
Bridge
The container ship M/V Cosco Busan
struck the Bay Bridge in San Francisco Bay
at 08:30 on 07 November 2007. An
approximate 100' gash in the hull of the
vessel resulted, and 58,000 gallons (approx
200 tonnes) of fuel oil was released into the
water.
Impact

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Governor of California, Mayors of Berkley
and San Francisco declared a state of
emergency in the Bay Area
About 200 miles of coastline was affected
by spill, 26 miles seriously contaminated
More than 1,854 birds of 45 species killed
Large numbers of the public involved as
volunteers in the cleanup and rescue and
rehabilitation of wildlife
San Francisco Bay Bridge Tower D
Container Ship ‘Cosco Busan’
Length 275m, Breadth 40m, Draft 12.20 m Crew 23
M/V COSCO BUSAN
 Navigation
Equipment
- 3 cm Radar
- 10 cm Radar
- Electronic Chart System (ECS)
- Conning Information Display
- Automatic Identification System
(AIS)
NTSB
NTSB
NTSB
NTSB
Relative Experience

Pilot
- Bar Pilot for 27 years
- A few thousand trips under the Bay Bridge
- Not uncommon to operate in fog
- Recurrent training for ship-handling in simulators and
manned scale model vessels

Master
- Master for 10 years
- 2 weeks with company, vessel and crew
- 1st time in San Francisco Harbour
- 1st time under way on ‘Cosco Busan’ without company
supervisors
Timeline
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0620 Pilot on board, heavy fog
0810 Ship leaves berth
0820 In bar channel, turn to port
0822 Discussion about red triangles
0823 Turn to port
0826 Turn to starboard
0827 VTS contacts ship
0830 Allision with D Tower
NTS
NTSB
Track from undocking until impact - NTSB
NT
Ground track prior to collision - NTSB
Cosco Busan – Specific Charges
1. Clean Water Act – Negligent Discharge of a Pollutant
JOHN JOSEPH COTA,
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did negligently cause the discharge of oil in such quantities as may be harmful from a
vessel, the M/V Cosco Busan, into and upon the navigable waters of the United States,
without a permit. Specifically, on or about November 7, 2007, Defendant Cota, while
piloting the M/V Cosco Busan, caused approximately 58,000 gallons of heavy oil to be
discharged from the vessel into San Francisco Bay by acting in a negligent manner, that
included the following:
(a) failing to pilot a collision free course;
(b) failing to adequately review with the Captain and crew of the M/V Cosco Busan prior
to departure the official navigational charts of the proposed course, the location of the
San Francisco Bay aids to navigation, and the operation of the vessel's navigational
equipment;
(c) departing port in heavy fog and then failing to proceed at a safe speed during the
voyage despite limited visibility;
(d) failing to use the vessel's radar while making the final approach to the Bay Bridge;
(e) failing to use positional fixes during the voyage; and
(f) failing to verify the vessel's position vis-à-vis other established and recognized aids to
navigation throughout the voyage.
All in violation of Title 33, United States Code, Sections 13 19(c)(l)(A) and 1321(b)(3), a
Class A misdemeanor.
2. Migratory Bird Treaty Act
JOHN JOSEPH COTA,
without being permitted to do so by regulation as
required by law, did take migratory birds, including
at least one Brown Pelican, (Pelecanus occidentalis),
Marbled Murrelet, Brachyramphus marmoratus),
and Western Grebe, (Aechmophorus occidentalis).
All in violation of Title 16, United States Code,
Sections 703 and 707(a), and Title 50, Code of
Federal Regulations, Sections 21.1 1,20.71 and
20.72, a Class B misdemeanor.
CALIFORNIA BOARD OF PILOT COMMISSIONERS
INVESTIGATION CITES PILOT ERROR IN COSCO
BUSAN ACCIDENT
October 23, 2008
The Board of Pilot Commissioners today issued
a report of the investigation by its Incident
Review Committee (“IRC”) of the accident on
November 7, 2007.
The Board of Pilot Commissioners for the Bays of San Francisco, San Pablo
and Suisun was established in 1850 to provide State oversight for the San
Francisco bar pilots. The Commission licenses and regulates maritime pilots
navigating San Francisco Bay and its tributaries as far inland as the Ports of
Stockton and Sacramento, and In Monterey Bay. The Board's
responsibilities include training, incident investigation and rate determination.
IRC – Report
As a result of its investigation, the IRC concluded that
pilot negligence was a factor in the accident. The IRC
report summarized its conclusions as follows:
(1) Captain Cota failed to utilize all available resources to
determine visibility conditions along his intended route
when it was obvious that he would have to make the
transit to sea in significantly reduced visibility;
(2) Captain Cota had exhibited significant concerns about
the condition of the ship’s radar and a lack of familiarity
with the ship’s electronic chart system, but failed to
properly take those concerns into account in deciding to
proceed;
(3) That, considering the circumstances of reduced visibility
and what Captain Cota did and did not know about the
ship and the conditions along his intended route, he failed
to exercise sound judgment in deciding to get underway;
IRC – Report
(4) Captain Cota failed to ensure that his plans for the transit
and how to deal with the conditions of reduced visibility had
been clearly communicated and discussed with the master;
(5) Once underway, Captain Cota proceeded at an unsafe
speed for the conditions of visibility;
(6) When Captain Cota began making his approach to the
Bay Bridge, he noted further reduced visibility and then
reportedly lost confidence with the ship’s radar. While he
could have turned south to safe anchorage to await
improved visibility or to determine what, if anything was
wrong with the radar, Captain Cota failed to exercise sound
judgment and instead continued on the intended transit of
the M/V Cosco Busan, relying on an electronic chart
system with which he was unfamiliar.
(7) Captain Cota failed to utilize all available resources to
determine his position before committing the ship to its
transit under the Bay Bridge.
Pilot Sentencing
17 July 2009
Sentence

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Pilot received sentence of 10 months
imprisonment for violating Clean Water Act and 6
months for violating Migratory Bird Act. (Both
sentences to be served concurrently)
Two hundred hours of community service
Judge imposed no fine because of financial
obligations and multiple civil suits faced by pilot
Imprisonment to be followed by one year of
supervised release during which time pilot cannot
serve as a pilot or ship captain.
Medical issues not taken into account in sentence
Pilots as environmental stewards
“Today’s guilty plea is a reminder that the Cosco
Busan crash was not just an accident but a criminal
act. This is not a case involving a mere mistake.
The lesson here is that environmental stewards*,
who abandon ship, act negligently and cause
environmental
damage
will
be
vigorously
prosecuted”
John C Cruden, Acting Assistant Attorney General for
Justice Department’s Environment and Natural
Resources Division
* Steward in the biblical sense is someone who takes
care of something. (Knowledge of environmental laws
part of pilot licensing)
Alert to the Maritime Industry
“John Cota was an experienced pilot that was
handsomely compensated for his special knowledge
of ships and expertise in local waters. ...
This case should sound an alert to those in the
maritime industry that safety rules and procedures
are meant to be followed, safety equipment is meant
to be used, and that those who act otherwise and
despoil our natural wonders will be prosecuted to the
full extent of the law”
Joseph Russoniello U.S. Attorney for the Northern
District of California
Plea Agreement
Cota admitted that he:

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Failed to adequately discuss the intended route through San
Francisco Bay with the Master or crew as is required;
Failed to use the ship’s radar in the final approach to San Francisco
Bay Bridge;
Failed to recognise two red triangles on the ships electronic chart
system that actually are the buoys marking the bridge tower;
Failed to verify the meaning of the red triangles by using the ship’s
paper chart or radar:
Failed to inform the crew of his method of navigation that he relied
on using a particular radar setting; and
Failed to advise the crew of a radar beacon that marked the center
of the Delta Echo span
Pilot/Fleet Management - Civil
Lawsuits
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Class Action by 5 fishermen
City of San Francisco
State of California,
Two individuals who claim that they were subsistence fishermen and it is
in the Calif. constitution that they have a constitutional right to fish,
Fleet Management suing John Cota and San Francisco Bay Pilot’s
Association
Continental Insurance
(Continental Insurance is suing John Cota to return approx. $ 2,000,000
or more paid for his criminal defense. Since no pilot had ever been
criminally charged prior to this event criminal defense was not included
in the policy. The policy simply states "legal defense." Continental
Insurance is claiming foul and wants John Cota to return money. )
Also on all but the suit against John Cota by Fleet Management he is
named as a secondary defendant with Fleet Management.
Fleet Management
PLEA AGREEMENT
Fleet Mgt. Ltd. Agrees to Pay $10 Million
for Pollution and Obstruction Crimes

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WASHINGTON 13 August 2009 — Fleet Management Ltd., pleaded
guilty today to a criminal violation of the Oil Pollution Act of 1990 for its
role in negligently causing the discharge of more than 50,000 gallons of
fuel oil into San Francisco Bay from the Cosco Busan when the vessel
struck the San Francisco Bay Bridge in dense fog on Nov. 7, 2007.
According to the factual statement signed by Fleet Management, the
crew of the vessel:
Was not adequately familiar with certain ship-specific navigational
equipment,
Did not engage in a berth-to-berth passage planning process or prepare
written berth-to-berth passage plans,
Did not conduct an adequate Master – Pilot exchange of information,
Did not fully utilize or operate the ship’s radar and electronic chart
system, and
Did not take fixes during the voyage.
Fleet Plea Agreement
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Criminal fines are $8 million plus another $2 million in
community service payments to the Fish and Wildlife
Fund for a total of $10 million.
Three Years Probation.
During the term of probation Fleet will be subject to an
enhanced compliance program with a number of strict
requirements for various audits
Guilty pleas part of a plea agreement with the
government subject to approval by Judge Susan Illston
of the U.S. District Court for the Northern District of
California
Sentencing has been set for December 11 2009
Fleet Management
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Fleet admitted that after the ship hit the Bay Bridge, it
concealed ship records and created materially false,
fictitious and forged documents with an intent to influence
the Coast Guard’s investigation.
In particular, a false berth-to-berth passage plan for the day
of the crash was created after the incident at the direction of
shore-side supervisors known as superintendents and with
the knowledge of the ship’s master.
Additionally, a ship officer falsified the ship’s official
navigational chart to show fixes that were not actually
recorded during the voyage.
Other records including false passage planning checklists
were also created after the fact.
Industry Standards
Under recent law reform mere compliance with
industry standards may not be sufficient to
avoid a conviction. The fact that a given
practice is common within a particular industry
is a relevant factor for consideration but does
not of itself mean that observance of that
practice cannot fall far below what can
reasonably be expected. It will not be a defence
if a jury is not impressed by the standards
which the industry has set for itself.
Source: SEA EMPRESS PROSECUTION by Nick
Greensmith, Partner, Clyde & Co London
Paradox for Laypersons


Without any criminal intent John Cota
made an error of judgment. He is
convicted of a strict liability offence and
receives a jail sentence
Fleet management is only fined despite its
superintendents and officers falsifying
ships records etc with criminal intent
“This is a court of law young man, not a
court of justice” - Oliver Wendell Holmes Jr
‘Cosco Busan’ Strict Liability
STRICT LIABILITY

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Generally to be guilty of a crime, a person
must act with ‘criminal intent’
For health and public welfare violations
‘strict liability’ applies such as an ‘accidental
spill after a casualty’
Strict liability means that an individual can
be found criminally liable without having had
criminal intent in the traditional sense.
Strict liability offences carry heavy fines and
jail sentences
SA Fortius – Section 410B

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Decision 17 September 2004
Several points of law explored
- Negligence
- Contract law
- Invalid Pilots License
- Trade Practices Act
- Section 410B as being unconstitutional
SA Fortius – Section 410B

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Judge upheld ‘Statutory Immunity’ against
civil liability conferred by Section 410B
against all arguments
Good commercial reasons for upholding
Section 410B and not upsetting the
delicate balance.
Judge’s task is to deal effectively with
points of law. The court is assisted on
technical matters by expert witnesses.
Technical matters seen as a secondary
issue
SA Fortius – Section 410B
Negligence decision based on ‘proximate cause’
 Proximate cause – identified as failure to act by
the master when 150 metres off the berth
 Status quo maintained of pilot’s role in a ‘legal*’
sense as an adviser
 Use of ‘proximate cause’ based on a point of
law that is consistently applied in such situations
 Proximate cause approach the antithesis of a
‘root causes’ and safety management system
approach
* To accommodate ‘statutory immunity’. Does it
reflect reality?

‘SA Fortius’ Decision
“The decision shows once again (if there was
any doubt) that judicial intervention is solely
aimed at resolving issues of legal liability
and is not an effective means for
investigating accidents or human error with a
view to improving safety management”
John McCoy Former President Marine Board of
Victoria
‘Petriana’ (1903) to ‘Sea Empress’
(1996) and ‘Cosco Busan’ (2007
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Consequence of public concern for the protection and
preservation of the environment as expressed in
legislation:
Duty of care is extended to public and third parties
Not a consideration in the ‘Petriana’ case (1903)
First applied in the ‘Sea Empress’ grounding in Milford
Haven 1996
Again applied in the ‘Cosco Busan’ case (2007)
What would the legal consequences have been if the
‘Cosco Busan’ struck the bridge without any oil
spillage?
Pilotage Incident - Investigations
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Civil Liability – Fortius, Amarantos, Kourmala (Admiralty, Trade
Practices Act*) – Judgment based on ‘Balance of Probabilities’
Regulators (AMSA - Masters Certificate) – Prudent mariner test
Pilotage Regulator (Pilot License) – Breach of Code for Pilot
Licensing and or Harbour Masters Directions and Codes of
Practice ‘OOCL Sydney’
Criminal (Public Prosecutor) – Beyond Reasonable Doubt:
‘OOCL Sydney’
Safety Investigation [Australian Transport Safety Bureau
(ATSB) or State equivalent Systems approach (No blame Safety
Investigation)
Pollution – {Strict Liability – ‘Sea Empress’ (Milford Haven);
‘Cosco Busan’ (San Francisco)}
Others
*Tug Kourmala collision with Pernas Arang off Hay Point on
February 28, 1995. Ruling handed down on 19 April 2007 in
Queensland Supreme Court. Section 74 of the Australian Trade
Practices Act cited.
Food for thought
The late great US Coast Guard Captain Dominic
Callicchio, who reformed American maritime
law…, theorised
that so many
maritime rules were created so that
no rules were clear. This led to
confusion in operation and policy
but complete clarity in hindsight
and prosecution.
Very Low Incidence of Accidents
and Safety in Pilotage

Rarity of pilotage accidents shows limits of a statistical
approach in drawing meaningful conclusions with regard to
safety

Captain John Cota over a 27 year career had a record of
99.78% safe pilotages. The statistics for the Inner Route
Barrier Reef pilotage are close to 99.99%

Pilots cannot rely on statistics alone to prove they have
been operating in a safe manner after an accident. The
trend is to apply a ‘due diligence’ (‘duty of care’ or
‘standard of care’) test particularly
if there is
environmental pollution or loss of life.
Due Diligence
Where it is possible to guard against
a foreseeable risk, which though
perhaps not great, nevertheless
cannot be called remote or fanciful,
by adopting a means which involves
little difficulty or expense, the failure
to adopt such a means will in general
be negligent
From Richard Robinson R2A
Due Diligence
“Risk and liability is now based on
the very sensible ethical position
of the common law, namely that
all
reasonably
practical
precautions are in place based on
the balance of the risk versus the
effort required”
Richard Robinson - Diligence Engineer R2A
Due Diligence and Cosco Busan
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The primary defence against negligence is ‘due diligence’.
This means that a reasonable person (in the eyes of a
court) in the same position would have undertaken certain
procedures and processes to ensure whatever it is that did
happen, on the balance of probabilities should not have
happened
What could have guarded against the risk of the accident
occurring?
A Master/Pilot exchange (MPX) to develop a ‘shared mental
model’ leading to a passage plan with contingencies and
defined bottom lines and responsibilities (BRM)
What is the cost of conducting such a MPX?
A few minutes of time and the cost of the paper!
Expanded Notion of Due Diligence
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Role of VTS
Regulators Oversight
- Selection
- Training
- Medical Standards
- Operational Practices
- Competency checks
Pilot Organization
Tugs
Port & Hydrographic Service
- Standard Passage Plans for ports
Modernisation
MEETING CONTEMPORARY BENCHMARKS IN
‘DUE DILIGENCE’ AND ‘STANDARD OF CARE’
Modernisation – Implementation
Issues
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Involves shift from ‘pilot centred’ to a human
factors based ‘systems’ approach
Shift to ‘systems’ approach implies radical change
in ‘maritime culture’ in pilotage and particularly
‘professional culture’ of pilots based on the
‘traditional pilot centred’ approach
Maritime culture (legal, commercial, organizational
& operational) in pilotage based on legal notion of
the pilot as an independent professional person
contracted to navigate the ship but in a civil liability
sense considered an advisor providing local
knowledge to the master
Immunity of Pilot & Employer
The civil immunity of the pilot and his/her
employer withstood numerous challenges
from 1913 onwards on the basis of ‘lending
certainty to commercial dealings’ until the
‘Sea Empress’ grounding at Milford Haven
on 15 February 1996 and ‘Cosco Busan’ 07
November 2007.
Both cases involve environmental pollution
Human Factors - Shipping
“There is probably no enterprise that could profit
from the human factors consideration more than
merchant shipping. The accident figures are
incredible… The potential for CRM and other
human factors areas to contribute to the alarming
situation in the marine industry is great, but
whether it will ever be realized is difficult to say.
Safety standards in the marine world seem to be
resistant to even the most potent forces: loss of
life, loss of capital equipment and financial
liability.”
E.I. Wiener, B.G. Kanki and R.L. Helmreich (1993) Cockpit Resource
Management Academic Press Pages (494-495)
Implementation – Robert Helmreich
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BRM is an unrealized concept in shipping
Affects of culture (national, industry, professional and
organizational) on professional behaviour needs to be
understood and acknowledged
Nature of errors in the normal operational environment
need to be known.
Databases need to be built and maintained showing the
nature and frequency of errors
Multiple strategies need to developed for managing error
Finally full implementation will require structured
training using a high fidelity full mission bridge
simulator
Modernisation
CLARIFICATION OF PILOTS ROLE
Traditional/Historical
Justification for Pilot
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Local knowledge
National security
Independent judgment
(Seamen's Vade Mecum 1707)
Navigation expert needed in case masters judgment
overwhelmed by commercial pressures*.
Conforms with the latest ideas on risk management
and Leader/follower model
Commercial Risk: 18th century Swedish East India
ship carrying cargo equal in value to half the GDP of
Sweden
*(KLM/PANAM Accident 1977)
Vade Mecum 1707
The Duty of the Pilot
…...
8. No Masters of ships shall force Pilots to
pass through dangerous places, and to
steer courses against their will; and in
case of contrariety of opinions shall be
governed by the advice of the most
expert mariners
Modern Justification for Pilot
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Up to date knowledge of fairways and conditions
Expert shiphandler* in port conditions
Knowledge of regulations and by-laws
Port/State/National Representative involved in
protection of port/public/state interests such as
infrastructure and waterways
National Security
Independent Judgement
Must work with bridge team but also exercise independent
judgment if necessary. Leader/Follower model (BRM)

Expert in development & application of systems
approach to safety in piloting conditions (BRM)
*Not recognized in Admiralty Law (‘SA Fortius’)
Pilot Joint Manager of High
Risk Operation
Acknowledgement of pilot as joint manager of risk raises
knowledge of human factors to prime importance. Requires
development of ‘selection criteria’ and proper training in:




Shiphandling (manned model, on the job and
simulator based) using a competency based approach
Passage planning (Piloting to a passage plan)
Application of modern technology (Instrument
piloting)
Application of error management (BRM) principles and
techniques in pilotage
All above highlighted in the ‘Cosco Busan’ incident
In addition to local knowledge
Traditional Pilot Training
- Total emphasis on local knowledge
- Licensing based entirely on visual piloting
- On the job training
- Time based or number of trips
Not adequate to meet present day
demands of safety
Until recently no testing for aptitude, requirement for
simulator training, professional development etc
Modernisation – Pilotage
Software
(People)
Hardware
Materials, Design,
Machinery, Equipment,
(Portable Piloting Unit) etc.
Selection
and Training
Individual
Technical Skills
and Experience
Human Factors
Safety Management
System
Resource
Management
(Organization, Proactive,
Reporting)
Safety Culture
‘Holy Grail’
Modernisation - Australia



Modernisation (systems approach) an
Australasian Maritime Pilots Institute (AMPI)
initiative in 2002
Australia leading in understanding the need
for modernisation in pilotage. Understanding
has now achieved critical mass
Blueprint has been developed and is in
various stages of implementation in Australia
with Queensland leading
AMPI - Vision
Piloting within a BRM framework to a
passage plan with a reserve of
practiced and regularly validated skills
to deal with abnormal and emergency
situations
‘Truly superior pilots are those who use their
superior judgment to avoid those situations
where they might have to use their superior
skills’
Recent Initiatives



Development and implementation of Pilotage Safety
Management Systems (PSMS) including pilotage
operating procedures :
- Consensus on good practice
- Guidelines where consensus not possible
- Piloting to a passage plan
- Procedures for communication
- ‘Optimum speed’ and ‘track’
Pilots role defined in modern terms
Development and implementation of ‘No blame reporting
system’
Recent Initiatives - 2






Professional development (Advanced Marine
Pilots Training Course)
Human Factors (HF) Initiatives
Use of Portable Piloting Units and Instrument
Piloting Course
2nd Generation BRM Course
Development of ‘Shiphandling Questionnaire’
based on standard texts to establish baseline of
hydrodynamic knowledge
Manned Model Training in early stage of training
to consolidate technical knowledge and skills
Recent Initiatives - 3

Development of ‘Pilot Competence and
Performance Guide’ by AMPI

‘It works for me therefore it is right’


being replaced by an approach based on
hydrodynamic
principles
and
risk
management
Structured simulator training based on a
Competency Based approach for normal,
abnormal and emergency situations
Competency Audits incorporating technical
skills
Finally



A number of issues have emerged which are
having a major impact on critical aspects of
pilotage
It is best for pilots & regulators to understand
the issues
Addressing the issues requires a reappraisal
of several aspects of pilotage (Legal
framework, pilots role, selection, training,
operational practices, use of technology,
development and implementation of a proper
human factors based safety management
system etc.)
New Realities
‘Cosco Busan’, ‘OOCL Sydney’ and
other such incidents show that we
are now faced with new realities for
which there are no ready made
solutions.
We need to continue to seek, find,
develop, and implement solutions
appropriate to today’s needs
Finally
Pilotage is located at a strategic point
in the shipping industry. With the right
mindset pilots are in a position to
provide the leadership in helping the
shipping industry in understanding
and properly implementing a systems
approach
END
Thank You
Ravi Nijjer
Principal Consultant
Marine Consultancy Group Pty Ltd
Tel: + 03 9830 0649
Mobile: + 0419 565 860
ravi.nijjer@marcon.com.au