(WASHINGTON) — On Oct. 14, 2024, about 0412 local time, the crude oil tanker Platanos was undocking from the Martinez Refining Company wharf pier near Martinez, Calif., in the Carquinez Strait, when the vessel’s port quarter made contact with a concrete dolphin and a fender support panel of the pier. There were no injuries and no pollution was reported. Damage to the vessel and pier was estimated at $500,229.
The National Transportation Safety Board (NTSB) determined that the probable cause of the contact was the pilot transposing the tugboat positions on his reference card and subsequently issuing orders to each tug that were intended for the other while maneuvering the tanker off the dock.
“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,” the NTSB report said. “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 report said. “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 NTSB said. “The pilot may have also been affected by fatigue. While the pilot reported getting eight hours of sleep the night of Oct. 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 Oct. 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.”
Click here to read the complete report.
– National Transportation Safety Board
