The reporter expressed a safety concern relating to the management of large cruise ships entering [location 1].
The reporter advised that in March 2011, the pilot services risk assessment committee produced a risk assessment of the Port of [location 1] passenger vessels. The conclusion of this assessment was that all passenger vessels transiting west of [location 2] have a tug secured to the ship for emergency purposes.
The pilots proved that in the event of a loss of control, due to human factors or mechanical failure, a cruise vessel could be prevented either from grounding or having a collision with the [location 3] by using a tug.
During this risk assessment, anchoring was not considered in this area due to [location 4] and submarine cables.
When the port authority published the final risk assessment in October 2011, it stated that if a ship’s master declared that his vessel had been ‘incident free’ in the previous 30 days and all navigation and propulsion equipment was working 100 %, then the obligation to take a tug was waived.
The Port of [location 5], also administered by this Port Authority, insists on two tugs for the cruise vessels for commercial reasons. The management of that port do not want the coal supply chain jeopardised by a cruise vessel incident.
The Port Authority survey chart for the area west of [location 2] carries the following note:
‘CABLE AREA: Vessels are warned that anchoring is not permitted under any circumstances in the area between the pecked lines extending south from [location 5] and [location 6] and across [location 7].’
In addition to the submarine cables, the area also contains the [location 4], which spans the middle of the manoeuvring area and lies in a trench just below the seabed.
Pilots were recently advised to deploy the vessel’s anchors in this area if an incident occurred.
The reporter advised that even if anchors were deployed, there is no guarantee that they would prevent a grounding or a collision. The pilots are very uncomfortable with the prospect of dropping 15 -24 tonne anchors near [location 4] or near the submarine cables.
The reporter also advised that two large cruise ships were recently granted dispensations after they advised of mechanical issues:
- [Vessel 1] was allowed to berth without tugs in [location 1] on the [date] and [date] even though her bow thrusters were only 66% operational.
- [Vessel 2] limped into [location 1] on the [date] with only one propulsion unit operational. She was then allowed to berth and un-berth 5 times in [location 1] without a tug, within the 30 day incident free period, on the [date], [date] and [date].
- [Vessel 1] has also had a complete blackout in [date] whilst alongside at [location 1]. The ship had advised that 5 out of 6 of the ships generators were available.
The reporter advised that very few cruise vessels that trade in [location 1] have full redundancy with continuous power availability. There is an unknown recovery time from a blackout until power is restored, and often this is only to 50% power. A drifting ship can experience one knot of current and additional speed from an onshore wind that would carry it towards the [location 3] in less than a couple of minutes.
The lack of a tug leaves a gaping hole in defences in the event of a human factors error or a machinery failure on departure or approach to [location 1], which could have catastrophic consequences.
The scenarios have been rehearsed on the simulator at the Australian Maritime College and the solution was found to be a tug made fast on the centre lead aft.
Operator's response (Operator 1)
Before addressing the specific issues raised in the letter, we believe it is appropriate to consider the overall safety management approach for [location 1], as there are a broad range of measures that are adopted by our teams. We also believe it is worth highlighting some of these, in order to provide a better opportunity for those who may be concerned, to understand the systems and procedures used by the Port Authority.
It is our intention to provide this transparency to the systems operated, with the aim of avoiding the potential for individuals to draw conclusions based upon a narrow, and potentially historic, perception of cruise and port operations or perhaps an alternate view that is based on some other misconception or differing views. It is also worth noting that the opportunity exists for issues such as that raised in the letter, to be formally (or informally) and routinely addressed in regular consultative and working group meetings. Indeed the specific issue of the towage requirements for cruise vessels was discussed at both the recent pilotage technical committee meeting and the general pilotage meeting.
The Port Authority is also subject to annual audits, which specifically cover the safety of port operations and we operate systems that encourage and provide for the reporting of operational and personal incidents and accidents. Of course, discussion does not always lead to complete agreement with all parties, and it is our role to consider all the views, inputs, and experiences to determine the best approach to a particular concern. In making the final determination, we do recognise that some individuals and/or stakeholder groups may not be entirely satisfied. However, we remain confident that the systems in place in the Port Authority are well considered and robust and we are satisfied that the further explanation below should address the apparent concerns forwarded by you.
For the last five years, our team has worked closely with shipping companies and other stakeholders to recognise the advances in technology and understanding that can be adopted with the aim of advancing the efficiency of the safe operations we undertake. We have no direct responsibility for the operations in [location 5] and therefore we offer no comment into any procedures, adopted or otherwise, in that port. However, my experience both as a Harbour Master and as an observer of practices in other cruise ports clearly shows that [location 1] is operating in a broadly comparable manner to those other international ports.
Advances in survey technology have supported changes in under keel clearance allowances and these have, in turn, supported the opportunity to accept larger cruise vessels into the [location 1] and to berth at the [passenger terminal].
Arrangements with a commercial weather service provider, have enhanced the forecasting information we receive and this has enabled us to improve our planning and responsiveness to changes in environmental conditions, which had been causing increasing difficulties. The use of improved forecasting information has been supplemented with an increased number of local instruments, recording local conditions, and thereby supporting enhanced real-time decision-making processes.
The routine use of simulators, to provide confirmation and assurance of proposed manoeuvres, is a practice that has further expanded the capability of the port. The provision of portable pilots units for use by all the pilots is another recent development, which can only serve to enhance their capability and the shared understanding of other key individuals such as the vessel traffic service (VTS) operators and managers, who are monitoring vessel movements.
Of course, these advances are never universally welcomed and undoubtedly, there are individuals who find it more difficult to adapt to changes. Therefore, it is important that we work in an open and transparent manner to try to ensure that training and demonstration provide opportunities to develop greater understanding and acceptance of advances that may be considered new, despite being proven in many other ports around the world.
In focussing more specifically on the pilotage and towage operations highlighted as a concern, we are happy to confirm that a full risk assessment was first undertaken in mid-2011 for [location 1] based operations. The conclusions of that assessment have formed the basis for our current approach to the use of tugs for vessels operating in the vicinity of the [location 3], including cruise vessels transiting to/from the [passenger terminal]. We can also confirm that a full review of the Safety Management System (SMS), covering pilotage operations, was completed as recently as 2014 and it has been the subject of regular updates thereafter.
As an action from the risk assessment process, which was completed with full transparency amongst stakeholders (including pilots), it was determined that there were three stated conclusions:
- Masters of passenger ships bound for [location 1] are to provide a declaration to the Port Authority, at least 36 hours prior to arrival at the pilot boarding ground, stating that no incidents have occurred on board their ship, within the previous thirty day period, which have adversely affected the vessels manoeuvring capabilities.
- In the absence of the aforementioned declaration, all passenger ships transiting west of [location 2] to have an appropriately certificated tug of a minimum 45 tonnes bollard pull in attendance and secured to the ships centre lead aft.
- Pilots to include within their training, actions to be taken in the event of a complete loss of passenger ship manoeuvring power in Zone 4 (Zone 4 is an area in the vicinity of [location 3]).
In relation to points 1 and 2 above, I can confirm that systems have been operating since 2011 to capture information from cruise vessels and this information is used to determine the towage requirements for such vessels. The author of the letter sent to you, suggests that any declaration which highlights an issue, automatically determines that a vessel requires towage. However, that is not the case, as the declaration simply provides a case by case opportunity to review the towage requirements. Based upon the information received, the issue is considered by the VTS manager and/or the duty pilot and, where necessary, by the duty harbour master and/or the Harbour Master. This was the case for each of the vessels highlighted in the letter of concern. We believe this opportunity for cruise operators to provide detailed assessments of their operating capability, ensures that any risks associated with their manoeuvres within [location 1] can be and are being carefully managed.
We do acknowledge that there remains further work to be undertaken in relation to point 3 above.
We are keen to ensure that the Port Authority and its pilots adopt a more consistent and uniform approach to routine and emergency manoeuvres. However, this is a significant cultural shift, and once again, not all individuals recognise the benefits of such an approach and therefore this remains a 'work in progress'.
In considering the [Vessel 2] 'limping' into port, I am able to confirm that the cruise operator had directly contacted us over 24 hours prior to arrival to inform me that there was an issue with the vessel and therefore the vessel would arrive late on the day in question. The cruise operator had already ordered towage in anticipation of our requirements to do so, thereby limiting exposure to additional towage charges. However, the nature of the repairs was such that we did not require an ongoing towage requirement subsequent to the delayed arrival. We can only repeat that the published directions should not be considered as arbitrary as they serve only to provide a mechanism to consider issues in advance of a pilot boarding a vessel otherwise unaware.
In considering the total blackout of the [Vessel 1] while alongside the [passenger terminal], correspondence determined that the vessel had five diesel generators (DG) available and ready to start. During testing, DG , was the only DG in use at the time and remained ‘out of service’ for the departure while under investigation. The issue was caused by a commissioning test and not by an unplanned failure. The test did not affect manoeuvrability or navigation capabilities. Since all thrusters were available with 100% power the master indicated he did not require towage for departure, this confirmation came too late and I can confirm that this vessel was required to utilise towage for the departure but there was no such requirement for subsequent manoeuvres. We see this as a clear example of the systems we have in place working as intended and not as a matter for concern.
Of course, a key component of the safety concern raised lies in the assumption that a vessel will be subject to a complete power failure requiring the use of a tug to ensure an accident is avoided. This ignores the levels of sophistication on board the vessels operating in [location 1]. In considering the redundancy of cruise ship propulsion systems, it is well understood that cruise ships benefit from greatly enhanced redundancy and duplication of power systems when compared to other vessel types. By way of example:
- [Vessel 3] has 4 power units
- [Vessel 2] 6 power units and 2 electric podded azimuth thrusters (azipods)
- [Vessel 4] has 8 power units and 4 azipods
- [Vessel 5] has 6 power units and 2 azipods and in the unlikely event of a power failure in all of these units, the emergency diesel generator will provide power to the azipods in 24 seconds. Uninterrupted power supply and emergency batteries also ensure that key navigational equipment remains in operation, in the event of a complete power failure.
Clearly not all individuals, even experienced pilots, are aware of all of the levels of back up which exist to avoid an incident. This could be a contributing factor to them identifying towage as a requirement. Of course, the argument could be extended to include a backup for the tug in case of a towage failure, but as previously stated, it is part of our role to find a balance to such arguments.
In relation to the ultimate requirement to use an anchor should all else fail, I have no doubt that in the extremely unlikely situation that no systems remain in place, irrespective of the presence or otherwise of towage, then a prudent master would use his anchor to prevent further incident. To this end, the pilots have been provided with full details of the location of [location 4] - which we are advised is fully protected in the event that a ship’s anchor is purposefully or inadvertently dropped upon it. Work is being undertaken, to provide up to date details of any cabling in the location marked as a no anchor zone. We fully understand that using a tug in certain circumstances allows specific manoeuvres to be carried out in a given manner. Therefore, the safety concern highlighted in the correspondence, centres on whether or not those circumstances will ever arise and it is our contention that the risk is negligible.
We believe that a procedure, that has fully considered the potential for an incident caused by a complete and irreversible power failure in all systems, while the vessel is operating at very low speeds in favourable weather conditions and where planned and unforeseen repairs to mechanical systems during the previous thirty days have been reported and considered, provides a robust and well balanced approach to safe operations in [location 1]. Particularly when considered alongside the fact that there is universal agreement that the vessels in question do not require towage for their manoeuvring purposes in [location 1] and that when the wind speed is above 15 (or in some cases 20) knots then automatically there is a requirement for towage to be used.
We trust that the above explanation clarifies our position in relation to operations in [location 1]. We acknowledge that some individuals may remain concerned and there may be those that believe towage is required in port areas for all vessels at all times irrespective of the broader circumstances.
However, we remain happy to be contacted in relation to any concerns that may exist, as it remains our intention to ensure that all views and opinions are carefully considered prior to drawing conclusions and determining policies thereafter.
Regulator's response (Regulator 1)
The report was forwarded to Transport for NSW as the regulator responsible for this Port Authority:
Thank you for this REPCON report which we have considered closely.
We have analysed the response and have concluded that adequate safety processes are in place and that all risks in this matter have been properly assessed and mitigated.
A very similar concern was raised to the NSW Minister for Roads Maritime and Freight in a letter from a [location] pilot recently.
I was closely involved in that response, and the Minister was also advised that adequate safety processes are in place.
Regulator's response (Regulator 2)
The report was also forwarded to the Australian Maritime Safety Authority for their comment:
Thank you for providing a copy of the REPCON Marine Confidential Reporting Scheme report of concerns regarding the management of large cruise ships in [location 1].
The management of vessels arriving and departing within ports is a matter for the relevant Port Authority. AMSA notes the comprehensive response from the Port Authority and has no comment to make.
The ATSB had some further concerns in relation to this safety report and asked the Harbour Master further questions. The responses from the Harbour Master are in italics:
- In relation to the risk assessment conducted by the [loacation 1] Pilot Services’ in March 2011 – has this been reviewed to look specifically at the use or non-use of the tug?
The purpose of the risk assessment being undertaken in the first place was to answer this specific question and the conclusions were as described in my initial response and form the basis of the procedures we have been following without incident since 2011.
- What is the process for granting exemption/dispensation from tug use, specifically which parties are involved in the decision-making and the process for arriving at the decision?
As per our initial response, namely: Based upon the Declaration received from a vessels master, any issues are considered by the VTS manager and/or the duty pilot and, where necessary, by the duty harbour master and/or the harbour master. This was the case for each of the vessels highlighted in the letter of concern and has also been the procedure for other similar scenarios. We believe this opportunity for cruise operators to provide detailed assessments of their up to date operating capability ensures that any risks associated with their manoeuvres within [location 1] can be and is being carefully managed.
- Is there a risk analysis applied to this decision?
An analysis of the information provided by the ship is undertaken and appropriate action is determined based upon an understanding of that analysis.
- In relation to the dispensations:
a. How many applications do you receive?
It is a mandatory requirement for every cruise vessel seeking a dispensation to forward this request directly to the VTS prior to arrival. Therefore, we receive notification from every cruise vessel bound for the [passenger terminal].
b. Of these, how many are approved?
The significant majority of notifications inform that there are no on-board issues and therefore approval is granted to these vessels.
c. How many of the approved dispensations relate to mechanical problems with the propulsion / steering of the ships?
We do not keep specific records detailing these numbers, although the requests themselves are retained and filed. However, as the process is such that any issues are considered by the VTS manager and/or the duty pilot and, where necessary, by the duty harbour master and/or Harbour Master, we can confirm that concerns have only escalated to the Harbour Master on a handful of occasions and typically this will result in additional towage being provided. If the query does not escalate to the Harbour Master, then it is either because the requirement for towage is obvious or the entitlement to dispensation is similarly clear.
- Is there any basis for your contention that the risk for not using the tug is ‘negligible’ – Is this from historical data or another source?
My contention is that the multiple layers of control and redundancy which have been implemented are so significant that introducing unnecessary towage serves, in my considered view, a negligible purpose. Historically, there have been no occasions where cruise vessels operating to/from the [passenger terminal] have suffered complete power failure at or near the [location 3] - with or without towage. We are also unaware of any comparable incidents anywhere in other cruise ports.
In essence, the mitigation historically offered by towage has, in our view and that of other stakeholders, been more than amply replaced by increased mitigation from other control measures – most notably the technical enhancements made to cruise vessels themselves.
- Is there any evidence that there is general consensus from the [location 1] Pilot Service that they are happy with the decision not to use a tug in [location 1] for these cruise ships?
Prior to this safety concern being raised by an individual the only time the issue has been raised with us since the risk assessment was completed in 2011 was immediately following the routine pilot meeting in the final quarter of 2015. The minutes of that meeting reflect agreed actions to seek further information. However, no such actions were initiated and this safety concern process suddenly arose. Our conclusion is that there are a small number of pilots that may be unhappy with the decision, but for any similar scenario, pilots that have an immediate concern routinely raise that concern with us, and/or the Pilot Manager and it will be immediately addressed.
For reasons that are more likely linked to the mindset of a particular individual, this issue has been highlighted outside of the usually followed protocols and without the support of the Pilot Manager. There is no evidence of a general consensus that pilots are unhappy and in all other regards the working relationship is open, transparent and built upon mutual respect.
- Is there a time plan to conduct a review in the new process to measure the effectiveness of the procedure?
Further work has already been initiated, to review pilot training and to increase the understanding of all parties in relation to the presence of underwater cabling in [location 1]. A full review of the Port Safety Management System is proposed and a new Port Services Manager has recently been recruited to lead this effort – The pilotage SMS will feature as an important element within the Port SMS and the effectiveness of this and other procedures will be monitored therein.
In this regard, the process of conducting a review is already underway and any decisions would be informed by the further data and analysis being undertaken. I am not supportive of reaching snap conclusions without having thoroughly reviewed all the available information and that has been my position since this was raised shortly before Christmas and throughout the period since this ‘immediate concern’ was raised almost 5 years after the previous review.
The ATSB further questioned the Harbour Master and again their response is in italics:
- The original risk assessment was carried out in 2011. Was this assessment considered by the Port Authority as the official risk assessment and was this used as the basis for your safety management system and the piloting procedures used for vessels within the [location 1]?
This assessment was undertaken with the involvement of all stakeholders for the specific purposes of being the official risk assessment and forming the basis for operations and procedures thereafter, which it has been since 2011.
- If it is the official risk assessment, when the procedures for piloting the cruise vessel were released, the use of a tug, which was considered a risk mitigation in the event of a vessel losing power or steering, was not required, if the arriving vessel had no technical difficulties within the previous 30 days. Was a risk assessment conducted on this change, and how was the 30-day time-frame set?
This was not a change. This was an integral part of the assessment process and the identification of robust risk control measures. The 30-day period was developed in consultation with stakeholders.
- You have stated that the procedure in a non-normal event is to drop the anchor in a no-anchorage site. Was a risk assessment conducted on this procedure? Were the external stakeholders involved? Has an engineering inspection been conducted to consider the consequences of this action?
We have stated that in the event that all other levels of mitigation fail, a prudent mariner will inevitably use the anchors. This is a pragmatic and realistic observation which stakeholders are aware of. Following routine internal discussions in late 2015, it was determined that further work should be done to determine the extent of cabling within the area in the vicinity of the [location 3]. This work continues. However, it is becoming increasingly apparent that the cables in the area appear to be confined to a number of distinct locations and this will better inform future mitigation strategies.
This approach of gathering further information was the agreed approach embarked upon prior to the anonymous correspondence to which we are now responding and, in our view, further reinforces the benefits of gathering information and data prior to determining an apparent solution.
- Can you send us a copy of the risk assessments for dispensing with using the tug and for anchoring in the no-anchoring zone?
There is no assessment for dispensing with a tug, the assessment undertaken was related to potential failures of cruise vessel manoeuvring and this question presupposes the outcome that was being assessed. The risk assessment undertaken was related to measures to be considered in relation to cruise vessels operating to/from the [passenger terminal]. It is inaccurate and misleading to presuppose that there should be an assessment for dispensing with the use of a tug when considering vessel manoeuvres. Clearly, any assessment should be to determine whether or not a tug is actually required in the first place. The use of a tug is only one of a number of possible mitigation measures, which may be appropriate and the risk assessment undertaken concluded that no tug was required in certain clearly identified circumstances. Therefore, it is apparent that something that is not required does not require a separate risk assessment to determine if it should be dispensed with.
In relation to the use of anchors I have referenced this issue above.
In responding to the initial query and subsequent follow up requests for further information, I have a slight concern that a narrow focus is being given to the management of [location 1] activities, based primarily on the views of the initial correspondent. We are sure it is not necessary to put forward that broad consultation and a range of views are vital to ensure that the best outcomes are achieved, and I remain confident that the processes followed by the Port Authority do cater for a broad range of views. I also acknowledge that situations change and evolve and that is why I have had no hesitation in seeking further information from the cruise companies to facilitate a review of the risk assessment and from the cable owners to inform that assessment, a process that began late last year, prior to this concern being raised with you, and which continues today.
I appreciate your continued interest in this matter and look forward to your drawing this to a close.
As the ATSB remained unsure whether the procedures which had been applied by the Port Authority had been designed around the risk analysis which had been conducted by the [location 1] pilots group further questions were asked of the Port Authority. The Port Authorities responses are in italics:
We are sure you understand that as an independent body, we must ensure that any safety issue which is raised through the REPCON system is addressed.
From our perspective, we are not questioning whether the procedures you have in place are appropriate, but we are not confident that the risk analysis which was conducted to inform those procedures, was applied appropriately.
From our understanding, the risk analysis showed that a tug was required for cruise vessels when entering or departing [location 1]. This was required because even though the risk of a power or steering failure in ships of this nature is low, the consequences of this occurring could be catastrophic.
Having conducted this analysis, the Port Authority management then had discussions with the cruise ship management and the procedures subsequently did not required a tug when there were no reported technical issues within the previous 30 days. This may be a valid and safe procedure, but we do not feel that the appropriate risk analysis and detailed technical analysis of the redundancies of the different vessels, has been completed to ensure that all contingencies have been considered.
We are not implying that this approval should not be given, just that the appropriate analysis may not have been conducted.
We are also concerned that the appropriate engineering inspections and consultation may not have occurred between the Port Authority and the affected stakeholders, to investigate where it is safe to drop an anchor, in case of emergencies, within the no anchorage site in the [location 1].
We have recently received information advising that the Port Authority is about to/or has already started reviewing the original risk assessment. If you can advise that these additional issues will be dealt with in this process, the ATSB will be happy to close off the ATSB involvement in this issue.
We hope you can see that this process was to ensure that cruise vessels are safely entering [location 1] and we appreciate your patience in answering our concerns.
We do believe there may still be some lingering misconceptions in relation to the process and analysis that we and the Port Authority have followed to ensure that the safety of all ships entering [location 1] remains at the forefront of our considerations, however I see no benefit in seeking to further clarify our position.
Ultimately, it is important to ensure that there are periodic reviews of any and all risk assessments and I can confirm that I have already initiated this process in relation to the management of cruise vessels entering and departing [location 1].
Work has been underway for some time to ensure that the above review will be undertaken with the fullest of information available, including up to date locational and usage data relating to underwater cables and technical input from cruise operators. Once this data has been confirmed I will be inviting appropriate stakeholders, including pilot representatives, to assist in a review of the risk assessments we currently rely upon and updating Port Authority procedures as and where required.
The ATSB forwarded this response to the relevant department with oversight for this Port Authority within Transport for NSW. The following is their response:
I confirm that once the procedures for cruise ships entering and departing [location 1] have been reviewed and risk assessed, my department will review the new procedures under the current arrangements in place within our Port Safety Operating Licence, issued to the Port Authority of New South Wales by my department on behalf of the NSW Minister for Roads Maritime and Freight, in accordance with section 12(2) of the NSW Ports and Maritime Administration Act 1995.