Coast Guard probe of Chesapeake
grounding concludes that pilot may
have fallen asleep

Four tugs hold a barge in place during a lightering operation designed to free the collier after it ran aground. (Courtesy U.S. Coast Guard)

A collier ran aground in Chesapeake Bay because a drowsy bay pilot missed a buoy and the ship’s officers were afraid to correct his course because he had intimidated them, the Coast Guard has concluded.

The bow of MV Montrose grounded in mud Feb. 28, 2007, near the mouth of the Choptank River. The 712-foot bulker, hauling a full load of 74,215 metric tons of coal, failed to turn to starboard at fairway buoy CR.

The vessel was refloated a week later after a lightering operation removed enough coal to permit the ship to be freed from the mud.

Evidence suggests that both the Maryland state pilot and the mate on watch were negligent, investigators wrote in a January 2008 report. The Coast Guard recommends that the Association of Maryland Pilots review its work/rest requirements and improve training in bridge-resource management.

The Coast Guard said the bay pilot had only three hours of sleep when he boarded Montrose for the outbound transit, because he had been babysitting. Investigators concluded that the pilot was not alert at the time the ship went off course.

“The pilot was either asleep or had, as written in his statement to investigators, ‘lost attention,'” the Coast Guard report said.

“According to witnesses, the pilot had been sitting very still in his chair prior to the grounding, and it is our conclusion that the initial vibrations were what roused him from his sedentary state,” the report said, referring to the moment of the grounding.

Montrose should have turned to starboard at the mouth of the Choptank River but instead continued straight ahead. (Ginny Howe illustration/Source: Jeppesen Marine)

“By his own admission, he states that he should have been sleeping as opposed to staying awake with his girlfriend’s children,” the Coast Guard said. “The inadequate amount of rest contributed to the attention failures on the part of the pilot. We conclude that this lack of attentiveness caused him to miss the prescribed turn.”

Although the pilot had adequate time off beforehand, “he failed to exercise good judgment in adhering to a work/rest schedule that would leave him well rested for his duties,” the report said.

The pilot had been with the Association of Maryland Pilots since 1976. A second pilot was on board but wasn’t scheduled for duty until the second half of the 10-hour transit. The vessel got underway at Baltimore at 0055 and it grounded at 0600, so the pilot changeover was imminent.

The ship’s master had about 13 years experience, but this was his first-ever voyage as master. He was in his cabin showering at the time of the grounding.

The acting navigation officer, who had been sailing since 1974, was credentialed in India. He had been on Montrose for only eight days and had not done a southbound transit on Chesapeake Bay.

The Coast Guard investigation was conducted in conjunction with Liberian flag-state authorities. Montrose, en route to Romania, was managed by Motia Compagnia di Navigazione SpA, based in Venice, Italy. There were no injuries to the crew or damage to the vessel.

The Coast Guard concluded that the pilot’s authoritative demeanor contributed to a “breakdown in bridge communications” from the earliest stage of the voyage. After he boarded the ship at Baltimore’s Consol Energy coal pier, the pilot didn’t conduct or receive a navigation brief. The master prepared a Pilot Exchange Card, which specifies data concerning the ship’s size and propulsion and radar systems and the projected course into or out of the harbor, along with other information such as weather.

“The docking pilots signed the card, but the bay pilot did not, stating that he had ‘over 30 years as a pilot,'” the Coast Guard said. “This first interaction did not create or foster a relationship or dialogue between the bridge crew and the pilot. The master was sailing as a vessel manager for the first time, and may have been intimidated by the declaration of experience and the force of the pilot’s personality.”

The mate subsequently “failed to assert himself” and became “complacent.” He allowed the pilot to take full control of the vessel. The mate, however, had standing orders from the master to “seek clarification from the pilot” and notify the master if he had concerns about the vessel’s course.

“The mate on watch, in his statement, expressed that he had doubts about the course and position and was rechecking the vessel position when the grounding occurred, but took no action,” the Coast Guard investigators wrote.

The possibility of negligence charges against the pilot stem from his “fatigued status, his loss of situational awareness, and his overconfidence in his experience,” the Coast Guard wrote.

Negligence charges against the mate are possible because, while conning Montrose, he “abdicated his navigational duties and failed to follow standing orders,” the report said.
The report suggests that the Coast Guard and the Association of Maryland Pilots should discuss the feasibility of written 96-hour work/rest requirements and “time on bridge” watch standards.

The investigators want the association to revise its bridge-resource management training to foster a “team” atmosphere.

They also recommend that the association require a formal navigation brief on every watch and formally instruct the pilots to halt the transit if a master or officers in charge abdicate complete navigational control to the pilot.

Capt. Eric Nielsen, president of the Association of Maryland Pilots, said in February that it’s too early to specify what changes will be made. Nielsen said the Coast Guard’s report was addressed to the State Board of Pilots, which will instruct the association later.

“We look forward to working with the Coast Guard on all of these recommendations here,” Nielsen said.

Any improvements to the pilots’ bridge-resource management training will likely be integrated into course work they take at the Maritime Institute of Technology & Graduate Studies, Nielsen said.


See related article, NTSB labels Coast Guard efforts to address mariner fatigue as ‘unacceptable’

By Professional Mariner Staff