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Concern summary

The concern related to the procedures in use when piloting cruise ships as they entered the port.

Reporter's deidentified concern

In March 2011, the pilot services risk assessment committee produced a risk assessment of the Port of [Location] passenger vessels. The conclusion of this assessment was that all passenger vessels transiting west of [Location] have a tug secured to the ship for emergency purposes.

However, when the port authority published the final risk assessment in October 2011, it stated that if a ship’s master declared that their vessel had been ‘incident free’ in the previous 30 days and all navigation and propulsion equipment was working 100%, then the obligation to have a tug boat was waived. The reporter was concerned that a vessel being ‘incident free’ in the past 30 days was not sufficient criteria to exempt a vessel from utilising a tug.

The ATSB was not confident the risk assessment process had been appropriately applied to the tug exemption, and sought further clarification with the port authority on a number of points.

The port authority advised that their risk assessment process and subsequent procedures were appropriate and that the risk of a total loss of control of a passenger vessel was extremely unlikely. The regulator advised they were satisfied with the port authority’s assessments.

The port authority further advised that work was underway to ensure that a review would 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 had been confirmed, appropriate stakeholders, including pilot representatives, would be invited to assist in a review of the risk assessments and port authority procedures updated as and where required.

The reporter contacted the ATSB in 2019 advising that the agreed review and risk assessment into the procedures had not been finalised.

Safety outcome:

Given the lack of resolution to this safety concern, in 2020 the ATSB contacted the port authority outlining residual risk concerns with respect to inclusion of human factors, cyber threats and recent cruise vessel berthing incidents in Venice and other ports. The port authority invited the ATSB to review the draft hazard identification study and navigation risk assessment.

Following a review of the risk assessment, the ATSB advised the port authority and the state regulator that:

The hazard identification exercise and most of the report’s recommendations appear to be directed at identifying the hazards and mitigating the risks associated with tug-exempt cruise ship scenarios.

It is the ATSB’s view that in excluding the option of a mandatory tug escort for cruise ships in the hazard identification and risk assessment exercises, a valuable opportunity was lost to consider and analyse all potential risk control measures.

The ATSB notes the report’s assessment that the likelihood of the worst credible scenario—a cruise ship grounding on [infrastructure] or a collision with the [landmark]—is extremely low. The assessment is also clear that the consequences of either of these events have the potential to result in a catastrophic loss of life and/or infrastructure.

While the ATSB acknowledges that implementation of some or all of the recommendations in the commissioned report would likely reduce the risk of an incident involving a tug-exempt cruise ship, the value of a mandatory tug cannot be understated.

The ATSB considered the following points: 

 - the number of recommendations aimed at reducing the consequences of an incident involving a tug-exempt cruise ship, including potential modifications to cruise ship departure manoeuvres.

- the magnitude of any consequences associated with a [landmark] incident, noting that the [landmarks] could potentially effect 6,000 people in peak hour traffic, and the force of a cruise ship grounding would most likely lead to an infrastructure collapse.

 - lack of any evidence to suggest that there is a negative safety impact of tug-escorted cruise ships.

Based on this consideration, it is the ATSB’s view that the most demonstrable, effective measure to mitigate the identified risks, is the use of at least one tug for cruise ships navigating [Location]. As such, the ATSB encourages the port authority and the regulator to review the current criteria for granting tug exemptions to cruise ships.

The ATSB received advice in early 2021 from the newly appointed Harbour Master, and subsequently confirmed by the reporter, that there are no more tug exemptions being issued to large passenger vessels berthing at [Location].