NTSB: Pilot’s orders to tugs led to tanker Platanos’s costly contact with a California pier

The National Transportation Safety Board has released its report on an incident involving the 820-foot long, Bahamas-flagged tanker Platanos. At about 4.12 a.m. local time on Oct. 24, 2024, as a pilot was undocking the in-ballast tanker with the use of two assist tugs, the port quarter of the ship struck the northeastern corner of the Martinez Refining Company Wharf pier, near Martinez, Calif., shortly after getting underway, resulting in a hole in the ship above the waterline and damage to the pier.

There were no injuries, and no pollution was reported. Damage to the vessel and pier was estimated at $500,229.

NTSB ANALYSIS

In its analysis, the NTSB report says that “conning the Platanos at the time of the maneuver from the pier was an experienced San Francisco Bar pilot. He told investigators that before beginning the maneuver from the port bridge wing of the Platanos, when he wrote down the names and positions of the two tugs on his reference card, he transposed the names. As such, orders intended for the tug at the starboard quarter were given to the tug on the starboard bow and vice versa. The result was the bow being rapidly pulled away from the pier, causing the stern of the ship to move toward the pier in a 1.9-knot quartering current, which set the ship toward the pier. This was contrary to the pilot’s plan to pull the vessel’s stern off the pier quicker than the bow.

“Errors, such as slips and lapses, occur in the execution of routine or highly practiced tasks, and are often the result of an attentional shift, preoccupation, or distraction while performing the task. The pilot of the Platanos had a normal practice of writing down the names and positions of the tugboats that were assisting a vessel. However, on the morning of the contact, he transposed the names and positions of the tugs on his reference card. This resulted in the pilot having an incorrect mental model of the tugboat positions and the effect each would have on the Platanos as it maneuvered off the pier.

“It is possible that the pilot was interrupted or became distracted by another task while writing down the positions of the tugboats leading to the error. An interruption or distraction, such as concurrent discussions with ship’s crew, while marking each tugboat’s position could have shifted the pilot’s attention enough to cause the error. The pilot may have also been affected by fatigue. While the pilot reported getting eight hours of sleep the night of October 12–13, his sleep immediately before the contact was limited to about 4.5 hours due to having to report on board at 0330 on October 14. The contact also occurred at 0412, during a recognized circadian low period (0300–0500), when an individual’s desire for sleep is increased and performance effects are more pronounced. If the pilot was experiencing the effects of acute fatigue, he could have suffered a lapse in attention.

“One of the core fundamentals of bridge resource management is the ability for bridge team members to trap errors before they become an undesired occurrence.

“The master is ultimately responsible for the safety of the ship, which gives him the obligation to question and, if necessary, take over from the pilot in case he is in doubt of the pilot’s judgment. During the maneuver, about 30 seconds before the contact, it became apparent to the master that the vessel’s stern was too close to the pier, and he warned the pilot. The master was unaware that the pilot had transposed the tug positions and was issuing orders to each tug that were intended for the other. After the master warned the pilot, the pilot attempted to order measures to slow the stern’s movement to the pier. However, his order to have the aft tug pull full went to the forward tug. Given the short duration of time between the master’s warning and the contact, the lack of visual cues (in darkness), and the master’s unawareness that the pilot had transposed the tug positions, there were no actions the master could have taken at that point to prevent the contact of the ship with the pier.”

PROBABLE CAUSE

The National Transportation Safety Board determined that the probable cause of the contact of the tanker Platanos with the Martinez Refining Company Wharf pier was the pilot transposing the tug positions on his reference card and subsequently issuing orders to each tug that were intended for the other while maneuvering the tanker off a dock.

• Download the full report HERE