Report on P&I claims involving

vessels under pilotage 1999-2019

R E P O R T O N P & I C L A I M S I N V O LV I N G V E S S E L S U N D E R P I L O T A G E 1 9 9 9 - 2 0 1 9 02 / 03

CONTENTS WELCOME

04 EXECUTIVE SUMMARY On behalf of the International Group of P&I Clubs (the IGP&I),
it is my pleasure to present the updated IGP&I report on
06 INTRODUCTION
incidents for the period 1999 – 2019 that have given rise to
10 PILOTAGE DATA
P&I liabilities in excess of US$100,000 occurring when vessels
are under pilotage, and where it is considered that actions of
11 TOTAL INCIDENTS the assisting pilot have caused or contributed to the casualty.

13 ALLISION AND FFO INCIDENTS Through the unique structure of the International Group, the member
Clubs share between them their large loss exposures and their
respective knowledge and expertise on matters relating to shipowners
17 COLLISION INCIDENTS liabilities and the insurance and reinsurance of such liabilities, including
where liabilities arise when vessels are under pilotage.

21 GROUNDINGS The report recognises that there is generally a shared responsibility for
such incidents and, whilst the number and overall cost of the incidents
covered by the report are significant, when viewed with reference to
26 NAVIGATION INCIDENTS
the number of shipping movements in and out of ports worldwide in
any one year, the frequency of such incidents is low. Notwithstanding
32 COMMENTARY ON CAUSATION AND RECOMMENDATIONS advancement in training and technology, it is nonetheless likely
that there will continue to be incidents of loss or damage that arise
with vessels under pilotage. When such incidents occur, the report
34 ICS PILOTAGE TOWAGE AND MOORING SURVEY recommends that there should be more specific follow-up action
than has generally occurred to date. The need for engagement
of both pilotage bodies and port authorities in this regard cannot
36 BRIDGE RESOURCE MANAGEMENT (BRM)
be overstated. Collaborative engagement of all relevant parties
in investigating the causes of more serious incidents can only be
40 CONCLUSION - RESPONSE TO INCIDENTS of benefit to industry, and society as a whole, when identifying
measures that will assist in achieving sustainable risk mitigation
and loss prevention.
42 ANNEXES
The report reflects both the unique and invaluable forum that the
International Group provides for sharing information on such matters
of concern to Clubs and their Members, and the unparalleled source
of knowledge and expertise which can be brought to bear in exploring
and developing solutions and loss prevention measures. This resource
will be increasingly important in providing support in the challenging
and evolving times ahead for the shipping industry.

Paul Jennings
International Group Chairman
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EXECUTIVE SUMMARY

This report on incidents involving vessels under pilotage, When accidents occur whilst a vessel It is also suggested that navigational audits or reviews can be of
is under pilotage the cause is generally value in improving the quality of BRM, and that generic pilotage
is an update on that issued in 2006. The IG’s first report examined
a collective under-performance of the passage plans can help to facilitate the understanding of the pilotage
five years of data between 1999 and 2004. This report covers a
bridge team and it is recognised that approaches to unfamiliar ports and facilitate the preparation of
twenty-year period between 1999 and 2019 in which there were the ships’ masters and officers will also berth to berth passage plans.
1,046 incidents and resulting liabilities in excess of US$1.82bn have played a part. Consequently,
It is not considered appropriate or feasible to seek the establishment
the report recognises the importance
of regimes under which significant liability, backed by insurance,
to safe navigation under pilotage of
Whilst there is volatility in the number and severity of incidents in each year, should attach to pilots or the appropriate pilotage body as a means of
an effective Master-Pilot Information
the yearly average of 52 incidents equates to one incident per week, and the transferring liability exposure from the IG Clubs. Instead, a collaborative
Exchange (MPX) at the commencement
average value per incident is approximately US$1.74m. Whilst the overall cost approach is preferred whereby coordinated efforts are made by all
of the pilotage, and good Bridge
is substantial, the number of incidents is however very small in comparison stakeholders to investigate and determine the root causes of these
Resource Management (BRM) during
with the overall number of acts of pilotage undertaken every year. incidents when they occur in order to then identify and implement
the pilotage passage. The need to
remedial measures that will prevent recurrence.
The report considers incidents in four categories – Allision/Contact with Fixed reinforce training in these areas is
or Floating Objects (FFO), Collision, Grounding, and Navigation, the latter recommended. Many of the accidents giving rise to the claims that are included in
category encompassing incidents such as those caused by the wash of a vessel. this report do not appear to have been investigated by the relevant
These are not new issues and there
As may be expected, incidents in the Allision/FFO category constitute the majority flag states. Consequently, the report recommends the establishment
is nothing ground-breaking in this
– 60% of the total number – and cost in excess of US$1.14bn. Collision incidents of more structured arrangements to facilitate fact-finding, root cause
recommendation, but there are several
represent 31% of the total number and cost in excess of US$479m. analysis and risk mitigation measures, particularly for the more serious
areas of P&I liability exposure; such
incidents.
as entry to enclosed spaces, and
Although the report is focused upon data in the Clubs’ underwriting years up to and
accidents involving lifeboats, where It is recommended that consideration be given to the establishment
including 2018, there is comment upon some limited data for 2019. This is because
the underlying risk is long established of a Memorandum of Understanding arrangement with the entities
of the severity of three incidents in that year, all of which involve contacts between
and well recognised, and yet the risk responsible for pilotage in various ports or countries, pursuant to which
container vessels and gantry cranes. There have in addition been two more recent
continues to be the cause of repeated there should be a commitment to cooperate with the IG Clubs in
incidents of a similar nature notified to the IG Pool for the 2020 underwriting year.
casualties. Enhanced and repeated investigating the causes of the more serious incidents for the purpose
The berthing of large container vessels is identified as an area of focus for
training is an appropriate response of identifying measures that will assist in preventing further loss. Such
further work.
to such issues. an arrangement could initially and usefully focus upon the pilotage
bodies involved with the most serious container vessel/gantry crane
accidents, and the berthing arrangements for such vessels generally
given the frequency and severity of these claims. The Suez Canal
is also an appropriate area of initial focus given the frequency of
groundings in that waterway.
The yearly average
of 52 incidents equates Prior to publication, the draft of this report has been shared with
the International Maritime Pilots’ Association (IMPA) given the direct
to one incident per interest of their membership, and also the International Chamber of
week, and the average Shipping (ICS) in light of the 2016 ICS Pilotage, Towage and Mooring
Survey and their feedback has been taken into consideration.
value per incident is
approximately US$1.74m
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INTRODUCTION
For many years the ship owning members of the Boards of Directors
of the IG Clubs have expressed concern about the apparent
frequency and severity of P&I liabilities which arise whilst vessels
are under pilotage. As a response to that concern it was agreed
in October 2004 that data should be collected from all IG Clubs to
determine whether the frequency and severity of such claims was
increasing. This involved a requirement for Clubs to provide details
of claims exceeding US$100,000 where it was considered that
an error or errors on the part of an assisting pilot had caused or
contributed to the casualty giving rise to the claim. That exercise
resulted in the publication of the IG Pilotage Sub-Committee’s first
report on pilot error related claims in 2006. This was based upon
claims data for five underwriting years between 20th February
1999 and 20th February 2004.

In the last 20 years there

were a total of 1,046
incidents in which pilot
error either caused or
contributed to those events.
The total cost of those
incidents was over
US$1.82 billion
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INTRODUCTION

In 2013 there were two incidents where the cost of each was in
Since then data collection has Summary of Data 1999 – 2018
excess of US$5m and those claims constituted over 74% of the
continued and this report consolidates It can be seen from the data in Table 1 that in the 20 years to 20th total – just under US$79.5m. Each claim was in excess of US$35m.
claims information from 20th February February 2019 there were a total of 1,046 incidents in which pilot error
1999 to 20th February 2019. There are either caused or contributed to those events. The total cost of those Table 1
some limitations that apply to the incidents was over US$1.82 billion. On average this represents UW Year No. of Total Cost Average Allision Collision Grounding Navigation
data. In particular, the information 52 incidents per year, or one per week. There were four years in which Incidents Cost per and
Incident FFO
has not been updated to a date that the number of incidents were significantly greater than that average:- 1999 33 $21,761,748 $659,447 26 6 1 0
is consistent for the entire IG and it is
2000 47 $35,371,471 $752,584 29 13 5 0
not possible to resolve that. Further,
2001 70 $51,090,973 $729,871 45 21 4 0

$
there can also be no certainty that all
2002 52 $41,662,008 $801,192 38 9 4 1
qualifying claims have been captured
2003 56 $106,305,096 $1,898,305 35 16 3 2
in the data, because for individual 1,046 1.82bn 52 2004 59 $76,596,850 $1,298,252 29 20 10 0
Clubs the identification of claims to INCIDENTS INVOLVING TOTAL COSTS OF INCIDENTS PER YEAR
Collision denotes contact with another
PILOT ERROR THESE INCIDENTS ON AVERAGE 2005 46 $39,563,866 $860,084 20 20 5 1
be included in the data frequently vessel, and this constitutes the next
2006 54 $112,306,540 $2,079,751 29 20 5 0
involves a subjective selection. most frequent category of incident –
Four years in which the number of incidents were significantly greater than average 2007 57 $306,538,481 $5,377,868 30 20 6 1
Notwithstanding the limitations
2001 2012 2014 2015
2008 57 $50,811,280 $891,426 31 22 4 0 31% of the total.
however, there is a substantial body 2009 38 $149,212,660 $3,926,649 26 10 2 0
of data available as will be apparent 70 INCIDENTS
74 INCIDENTS
79 INCIDENTS
70 INCIDENTS
2010 32 $70,436,063 $2,201,127 23 7 2 0
Groundings represented
approximately 8% of the total
from the content of the report. 2011 59 $76,077,997 $1,271,310 32 25 2 0
incidents. The Navigational category
2012 74 $130,646,688 $1,765,496 49 21 4 0
The overall data collected by the denotes incidents where there has
The average cost per incident over the 20 years is approximately 2013 42 $107,118,832 $2,550,448 25 13 4 0
IG includes some claims information been no physical contact with the
US$1.74m. There were three years in which the average cost per 2014 79 $144,241,993 $1,825,848 39 32 7 1
for the 2019 underwriting year. This vessel - typically damages arising
incident was significantly greater than that figure: 2015 70 $134,125,800 $1,916,083 40 25 4 1
however is not included in the overall from the wash of a vessel. These
2016 42 $66,593,613 $1,585,562 27 9 6 0
analysis in this report because it incidents constituted approximately
2017 45 $42,425,808 $942,796 32 10 2 1
relates to information from a small 1% of the total.
2007 2009 2013
2018 34 $58,769,271 $1,728,507 25 8 1 0
number of Clubs and for less than a full It can be seen from Table 2 that
Totals 1,046 $1,821,657,039 $1,741,545 630 327 81 8
underwriting year. However, there are US$5,377,868 US$3,926,649 US$2,550,448
there is some correlation within each
some points of interest in the 2019 data category with reference to the
and these will be commented upon

57
percentages of the totals for each

38 42
In the categorisation of the incidents in Table 1, Allision and Fixed and
separately. category by number of incidents
Floating Object (FFO) denotes damage to a structure other than a
incidents incidents incidents vessel. This includes damage to docks, fenders, bridges, cranes and and their value. It is notable however
overall overall overall
other similar structures. As may be expected given the fact that a pilot that there is a slight adverse skew
is generally onboard a vessel to assist with its arrival at or departure for the Allision/FFO and Grounding
from a berth, incidents in the Allision/FFO category constitute the categories with those incidents being
majority – 60% of the total. proportionately more costly.
It is notable that the high average cost per incident figures in each of
the above years is driven by a very small number of high value claims. Table 2

In 2007 there were six incidents that resulted in claims each in excess Category No. of Incidents Approx. Value US$ % of No. % of Value

of US$5m, and those claims constituted over 88% of the total exposure
Allision/FFO 630 1,148,762,868 60% 63%
for that year – just over US$270.7m. One of those claims involved a total
cost of over US$200m, and one over US$20m. Collision 327 479,620,178 31% 26%

Grounding 81 190,532,761 8% 10%

In 2009 there were five incidents involving liabilities of more than US$5m
Navigation 8 2,741,232 1% 1%
and those claims constituted almost 74% of the total for that year – just
over US$110m. There was one claim in excess of US$50m. Total 1,046 1,821,657,039
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PILOTAGE DATA 2019 INCIDENTS

As mentioned in the Of the total exposure in 2019, two incidents have a total value of
US$45,503,400 which is 74% of the total. Although not in the data that
Introduction, the pool of data

TOTAL INCIDENTS
has been collected, there is a further incident in 2019 that has given
collected by the IG includes
rise to a claim notification to the IG Pool which brings the total value
some limited information for 2019 to US$83,729,216. On the basis of these revised figures, the
for the 2019 underwriting average cost per incident in 2019 rises to US$4,925,248 (see Chart 3) –
year. There are 16 incidents i.e. close to the previous maximum in 2007 – and these three incidents

reported with a total value of constitute over 80% of the total exposure. It is also notable that all three
incidents involve container vessels and damages to gantry cranes.
US$61,534,216. The majority of
those incidents (11) fall within It is also of interest to note that there have already been two claims
of a similar nature – contact between a container vessel and gantry
the Allision/FFO category. The
cranes - notified to the IG Pool in the 2020 underwriting year.
average value per incident for
2019 is US$3,845,888 which
At its face value, Chart 1 below indicates a gradually rising trend in the
is the third highest average
period 1999-2014. In marked contrast though, since 2014 the trend line
overall since the peak of is distinctly downwards. However, there is a need for some caution in
US$5,377,868 in 2007. placing too much reliance upon that trend.

Chart 1

Number of incidents per underwriting year

Total
1,046
90

80

70

60

50

40

30

20

10

0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

It is not inevitable that every IG Club will experience a qualifying

claim in every underwriting year. However, in the period 2010 to
2016 inclusive, claims notifications were received from a consistent
overall proportion of the 13 IG Clubs. In 2017 and 2018, that proportion
declined and therefore the total numbers of incidents in those years
should be regarded with some caution. It is self-evident from the
commentary above in respect of both 2019 and 2020 that as an issue,
the risk exposure from incidents that are the subject of this report
remains clearly visible.
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Chart 2

Total cost of incidents per underwriting year (US$1,000,000)

350
PILOTAGE DATA
300

250

200

ALLISION AND
150

100

FFO INCIDENTS
50

0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Chart 2 above depicts an upward trend in the total cost of these incidents in
the period 1999-2014 inclusive. The spike in 2007 is notable and as mentioned
earlier in this report, that is attributable to a single incident in that year which
cost in excess of US$200m. Without that incident, the record for 2007 would
have been comparable to that of the preceding year.

The decline in the total cost of incidents from 2016 onwards should similarly
be viewed with caution for the same reasons that were outlined in the
commentary to Chart 1.

Chart 3

Average Cost per incident (US$100,000)

60
Average Cost US$1.74m

50

40

30

20

10

0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Chart 3 depicts the average cost per incident in each year, and the average cost
per incident over the 20 years covered by this report. Information is included in this
chart for 2019 in order to illustrate the points made earlier in the report about the
impact of the small number of severe claims incurred in that year. The hatched
area of the 2019 column reflects the impact of the incident that is known from
IG Pool claim notifications but is not included in the IG’s data. The peaks in
average cost in 2007 and 2009 are clearly evident and commentary on the
reasons for those has already been made on page 8.
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ALLISION AND FFO INCIDENTS

As can be seen from Table 2 on page 9 Allision and FFO incidents represented the majority It is appropriate to make mention here of the small amount of data
by number and value, constituting 60% of the former and 63% of the latter. This adverse submitted for 2019 because this principally involves this incident
bias in respect of value highlights the financial severity of these incidents when they occur. category. There were 11 incidents reported with a total value of
It is to be expected that this category of incident will represent the majority since pilots US$57,287,216 – an average per incident of US$5.21m. If the further
are most frequently onboard for the purpose of assisting a vessel with its arrival at or incident in 2019 that is not currently in the data but which is the subject

departure from a berth. of a Pool claim notification is included (see page 11) the total for this
category in 2019 increases to US$79,437,216, an average per incident
The summary of data in respect of Allision and FFO incidents is set out in Table 3.
of US$6.62m. It is notable that this is approaching the peak average
in 2007 and that it is based upon substantially fewer incidents overall –
Table 3 12 in 2019 as compared with 30 in 2007.
In the 20 years since 1999 there have been
ALLISION & FFO Chart 4 depicts the number of Allision and FFO incidents per year. Although
Policy 630 Allision and FFO incidents costing a
Year there are some peaks of volatility, notably in 2001 and 2012, over the period
No Total Cost Average Cost total of almost US$1.149bn. The average
1999-2017 there appears to be little in the way of a discernible trend and
number of these incidents per year is 31,
26 $14,044,835 $540,186 general stability around the average of about 30 incidents per year.
1999 and the average cost per incident over
The downward trend that is evident from 2015 should be viewed with
29 $18,284,833 $630,511 that period is just over US$1.82m. There
2000 caution for the reasons set out earlier in the report.
were eight years in which the number of
2001 45 $35,911,612 $798,036
incidents exceeded that average and the
Chart 4
2002 38 $21,513,648 $566,149 most occurred in 2012 (49). There were
seven years in which the average cost Number of Allision and FFO Incidents per underwriting year
2003 35 $17,994,755 $514,136
of each incident exceeded the overall 60
2004 29 $50,534,871 $1,742,582 average, the most notable being in 2007

20 $23,394,526 $1,169,726 when the average cost per incident was 50

2005
approximately US$8.55m - almost
2006 29 $59,190,629 $2,041,056 5 times the 20 year average. This however 40
2007 30 $256,496,584 $8,549,886 was attributable to two incidents in that
year costing over US$200m and US$20m 30
2008 31 $21,503,942 $693,676
respectively.
2009 26 $73,354,824 $2,821,339 20

2010 23 $53,570,597 $2,329,156

10
2011 32 $33,391,985 $1,043,500

2012 49 $115,645,671 $2,360,116 0

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
2013 25 $96,665,027 $3,866,601

2014 39 $85,698,817 $2,197,406

2015 40 $56,366,253 $1,409,156

2016 27 $29,500,981 $1,092,629

2017 32 $35,493,831 $1,109,182

2018 25 $50,204,645 $2,008,185

2018 25 $50,204,645 $2,008,185

Totals 630 $1,148,762,868 $1,823,433

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Chart 5

Total cost of Allision and FFO incidents per underwriting year (US$1,000,000)
300

PILOTAGE DATA
250

200

50

100

50
COLLISION
0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Chart 5 depicts the overall cost of Allision and FFO incidents each year.
INCIDENTS
Information for 2019 has been included because of the substantial
cost of such claims in that year. The hatched area in the column for
2019 reflects the known claims experience for that year which is not
yet included in the data reported to the IG. The volatility in 2007 has
already been commented upon. Between 1999 and 2012 there is an
upward trend which then declines markedly between 2012 and 2016.
Since 2016 the trend has been upwards, and that trend is particularly
marked if the more complete total for 2019 is included.
Chart 6

Average cost of Allision incidents per underwriting year (US$100,000)

90

80
Average Cost US$1.82m

70

60

50

40

30

20

10

0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Chart 6 depicts the average value of Allision and FFO incidents each
year. The peaks of volatility in 2007 and 2019, and to a lesser extent in
2013, are clearly evident. The marked effect of incorporating known
additional data for 2019 can also be seen. The average cost per
incident is just over US$1.9m when including the more comprehensive
2019 data. There have been 8 years since 2006 when the record has
been above the 20-year average. In the period 1999- 2006 average
incident values were significantly lower than is generally the case
from 2006 onwards. The higher figures in more recent years results
from a combination of factors including larger ships, more
sophisticated and expensive port infrastructure, and cost inflation.
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Chart 7
Incidents falling into this category are those which
Total number of Collision incidents per underwriting year
involve contact with another vessel. Details of the data
35
in respect of Collision incidents are set out in Table 4.
30
Table 4 SUMMARY OF DATA FOR COLLISION INCIDENTS
25
COLLISION
Policy 20
Year No Total Cost Average Cost
15
1999 6 $5,582,749 $930,458

2000 13 $15,098,573 $1,161,429 In the last 20 years 10

2001 21 $9,538,710 $454,224 there were on average 5

2002 9 $5,821,959 $646,884 16 incidents per year 0

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
2003 16 $22,229,654 $1,389,353 and the average cost of
2004 20 $16,550,971 $827,549 each was approximately
Chart 7 shows the total number of collision incidents per underwriting year.
2004 20 $13,573,926 $678,696 US$1.47m The average is just over 16 incidents per year. The trend has been upward
2006 20 $30,437,682 $1,521,884 between 1999 and 2003, followed by a very stable experience for the next
five years until 2008. Thereafter the record has been much more volatile but
2007 20 $44,727,012 $2,236,351
with a generally upward trend between 2009 and 2015, and a peak of 32
2008 22 $19,470,277 $885,013 incidents in 2014. The downward trend from 2015 onwards should be
2009 10 $74,954,972 $7,495,497 regarded with caution for the reasons outlined earlier in this report.

2010 7 $16,009,207 $2,287,030

2011 25 $41,289,186 $1,651,567

Chart 8
2012 21 $11,649,961 $554,760
Total cost of Collision incidents per underwriting year (US$100,000)
2013 13 $6,306,102 $485,085 80

2014 32 $48,458,801 $1,514,338 70

2015 25 $68,745,269 $2,749,811 60

2016 9 $15,829,170 $1,758,797 50

2017 10 $5,281,371 $528,137 40

2018 8 $8,064,626 $1,008,078

30
Totals 327 $479,620,178 $1,466,728
20

10

There were 327 Collision incidents in the 20 years covered by this report 0
costing US$479.6m. There were on average 16 incidents per year and 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

the average cost of each was approximately US$1.47m. There were 10

years in which the number of incidents were in excess of the average,
Chart 8 depicts the total cost of collision incidents per underwriting year. Whilst
and 10 years when they were below. The highest number of Collision
there is year on year volatility, the trend between 1999 and 2015 is generally
incidents occurred in 2014 when the number was twice the average,
upwards. The downward trend from 2015 onwards should be regarded with
although the average cost of the incidents in that year remained
caution for the reasons that have already been outlined. There are two peaks of
close to the overall average. The most expensive years were 2009
severity in 2009 and 2015. As is generally the case with claims experience, volatility
and 2015 where the totals were US$74.9m and US$68.7m respectively.
is usually associated with small numbers of high value claims. This also applies
There were however far fewer incidents in 2009 than in 2015, 10 and 25
here. There was one serious incident in 2009 for which the cost was almost 84% of
respectively with the result that the average cost per incident in 2009 –
the total for that year. In 2015 there were three serious incidents which resulted in
US$7.49m – was the highest overall.
two claims in excess of US$8m and one in excess of $20m. Those three incidents –
12% of the total number in that year - accounted for 57% of overall value.
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COLLISION INCIDENTS PILOTAGE DATA

Chart 9 shows the average cost of Collision incidents per underwriting

year. The abnormality of the experience in 2009 is clearly evident and

GROUNDINGS
is the result of one extremely costly incident in a year in which the
number of incidents was well below the 20-year average. The converse
effect can be seen in 2015. Although there were three serious incidents
in 2015 – as shown in Chart 8 – the number of incidents in that year was
above average, thus moderating the outcome to a level closer to the
20-year average.

Chart 9

Average cost of Collision incidents per underwriting year (US$100,000)

80

70

Average Cost US$1.46m

60

50

40

30

20

10

0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
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GROUNDINGS

There were 20 incidents –

The data in respect of Grounding incidents is set out in Table 5.
25% of the total number
– that occurred in the
SUMMARY OF DATA FOR GROUNDING INCIDENTS There were 81 groundings in the There were five years in which the annual cost exceeded the
Suez Canal and cost average. The three costliest years were 2003, 2006, and 2016 with
period 1999-2018, an average
Table 5 of 4 per year. These incidents
a total of US$49.3m totals of US$64.9m, US$22.6m and US$21.2m respectively. These are
all attributable to single serious casualties in each of those years
GROUNDING cost US$190.5m – approximately which constituted 99%, 89%, and 76% respectively of the total for
Policy 10% of the aggregate for all each year. Two of these incidents occurred in the Suez Canal.
Year No Total Cost Average Cost
categories. The yearly average
1999 1 $2,134,164 $2,134,164 For the Grounding category overall, there were 20 incidents –
was approximately US$9.5m.
25% of the total number – that occurred in the Suez Canal
2000 5 $1,988,065 $397,613 As may be expected given the
and cost a total of US$49.3m.
2001 4 $5,640,651 $1,410,163
circumstances required for a
grounding to occur, the frequency
2002 4 $14,157,494 $3,539,373 Chart 10
of these incidents is much lower
2003 3 $64,979,060 $21,659,687 Total number of Grounding incidents per underwriting year
than that for the Allision/FFO and
12
2004 10 $9,511,008 $951,101 Collision categories. However,
2005 5 $2,112,852 $422,570 notwithstanding the lower
10
2006 5 $22,678,229 $4,535,646 frequency, the average value of
Grounding incidents - US$2.35m – 8
2007 6 $5,100,119 $850,020
is the highest of all and compares
2008 4 $9,837,061 $2,459,265
with averages of US$1.82m and 6
2009 2 $902,864 $451,432 US$1.47m for Allision/FFO and
2010 2 $856,259 $428,130 Collision respectively. 4

2011 2 $1,396,826 $698,413

2
2012 4 $3,351,056 $837,764

2013 4 $4,147,703 $1,036,926 0

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
2014 7 $9,961,006 $1,423,001

2015 4 $8,514,278 $2,128,570

The average number of Grounding incidents is about 4 per year.
2016 6 $21,263,462 $3,543,910
There were thirteen years in which there were four or more incidents.
2017 2 $1,500,605 $750,303 The low frequency makes it difficult to draw any conclusions as to
trend. 2004 was a particularly volatile year with 10 incidents, three of
2018 1 $500,000 $500,000
which occurred in Egypt and two in Saudi Arabia. The chart indicates
Totals 81 $190,532,761 $2,352,256 a downward trend since 2014 but no firm conclusions should be
drawn from this. The decline is from a low number and as previously
mentioned, caution is required in respect of the data in the most
recent years.
R E P O R T O N P & I C L A I M S I N V O LV I N G V E S S E L S U N D E R P I L O T A G E 1 9 9 9 - 2 0 1 9 24 / 25

When viewed with reference to the overall average cost of grounding This chart is somewhat distorted by the severe experience in 2003.
incidents of US$2.35m the volatility in this record is marked, particularly Less marked visually on this chart is the effect of the other two serious
the variance to the peaks in 2003, 2006 and 2016. As noted earlier in incidents in 2006 and 2016 respectively. It is noted earlier in this section
this section of the report these peaks are associated with single severe that the average cost of Grounding incidents is the highest of all
incidents in each year. The incidents which occurred in the Suez Canal categories. There is an upward trend in average cost between 2009
occurred in 2006 and 2016. and 2016, but because the number of incidents per year is relatively
low, there is a need for caution in drawing any conclusion from this.

Chart 11 Chart 12

Total cost of Grounding incidents per underwriting year (US$1,000,000) Average cost of Grounding incidents per underwriting year (US$100,000)

70
250

60
200
50

Average Cost US$2.35m

150
40

30
100

20

50
10

0 0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
R E P O R T O N P & I C L A I M S I N V O LV I N G V E S S E L S U N D E R P I L O T A G E 1 9 9 9 - 2 0 1 9 26 / 27

PILOTAGE DATA NAVIGATION INCIDENTS

This category of incident involves an absence of contact

by the vessel and principally comprises claims arising from

NAVIGATION the wash of the vessel under pilotage.

For the sake of completeness, the same data table and charts

INCIDENTS
for this category are included as for the others. However, there
is no detailed commentary or analysis simply because the
number of incidents and their overall cost is relatively small.

SUMMARY OF DATA FOR NAVIGATION INCIDENTS

Table 6
There were eight incidents in the
NAVIGATION
Policy 20 -year period. The total cost was
Year No Total Cost Average Cost US$2.74m, an overall average of
approximately US$137,000 per year.
1999 0 $0 $0 If the years in which there were zero
2000 0 $0 $0 incidents are excluded, the yearly
average cost becomes approximately
2001 0 $0 $0
US$392,000. The most incidents
2002 1 $168,907 $168,907 occurred in 2003 when there were
two which constituted 40% of the
2003 2 $1,101,627 $550,814
total exposure over the entire period.
2004 0 $0 $0 The average cost per incident is

2005 1 $482,561 $482,561 approximately US$343,000.

2006 0 $0 $0

2007 1 $214,766 $214,766

2008 0 $0 $0

2009 0 $0 $0

2010 0 $0 $0

2011 0 $0 $0

2012 0 $0 $0

2013 0 $0 $0

2014 1 $123,369 $123,369

2015 1 $500,000 $500,000

2016 0 $0 $0

2017 1 $150,000 $150,000

2018 0 $0 $0

Totals 8 $2,741,232 $342,654

R E P O R T O N P & I C L A I M S I N V O LV I N G V E S S E L S U N D E R P I L O T A G E 1 9 9 9 - 2 0 1 9 28 / 29

Chart 13

Total number of Navigation incidents per underwriting year

3 INCIDENTS BY COUNTRY AND PORT

These Tables 7 and 8 which show the number of Table 8 INCIDENTS BY PORT
incidents per country and port are included for the
1
sake of completeness. It must be emphasised however Houston 25 Abidjan 4
that no adverse conclusions should be drawn from Singapore 25 Amsterdam 4
the position in the tables of any particular country Antwerp 21 Barranquilla 4
0 or port. The figures of course reflect the volume of New Orleans 20 Busan 4
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
shipping traffic in each country. Data is not available to Suez Canal 17 Campana 4
determine the number of ship moves under pilotage in Kaohsiung 11 Genoa 4
each of these countries over the 20 year period covered Mississippi River 11 Jeddah 4
by this report, and therefore the numbers below cannot Alexandria 10 Karachi 4
be benchmarked with reference to such information. Port Harcourt 9 Kawasaki 4
Chart 14
Rotterdam 9 Kiel 4
Total cost of Navigation incidents per underwriting year (US$100,000) Shanghai 9 Kobe 4
12 Bangkok 8 Odessa 4
Table 7 INCIDENTS BY COUNTRY Douala 8 Port Kelang 4
10 Inchon 7 Tangier 4
USA 141 Cameroon 8
New York 7 Aden 3
China 64 Greece 8
8 Yokohama 7 Bremen 3
Japan 57 Philippines 8
Freeport 6 Cartagena 3
Egypt 47 Bahamas 7
6 Ho Chi Minh 6 Chiba 3
Brazil 38 Morocco 7 City
Argentina 31 Panama 7 Hong Kong 6 Copenhagen 3
4
United Arab Lagos 6 Dammam 3
Indonesia 30 7
Emirates
Osaka 6 Fremantle 3
2 Singapore 28 Pakistan 6
Port Said 6 Fujairah 3
Belgium 25 Tunisia 6
0 Rio De Janeiro 6 Haiphong 3
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
France 24 Algeria 5
Santos 6 Keelung 3
Saudi Arabia 24 Bangladesh 5
Yanbu 6 La Plata 3
Netherlands 23 Chile 5
Beaumont 5 Le Havre 3
Germany 22 Ecuador 5
Chittagong 5 Mumbai 3
United
22 Iran 5 El Dekheila 5 Ningbo 3
Kingdom
Average Cost US$0.34m

Chart 15 Taiwan 21 Jamaica 5 Guayaquil 5 Norfolk (Virginia) 3

Average cost of Navigation incidents per underwriting year (US$100,000) Canada 19 North Korea 5 Hamburg 5 Philadelphia 3

Spain 19 Russia 5 Jubail 5 Port Arthur 3

6
Australia 18 Ukraine 5 Kingston, 5 Ravenna 3
Jamaica
5 India 18 Denmark 4
Nagoya 5 River Parana 3
Nigeria 18 Ivory Coast 4
Piraeus 5 River Plate 3
4 South Korea 17 Norway 4
Surabaya 5 San Francisco 3
Italy 16 Congo 3
Zhanjiang 5 San Lorenzo 3
3 Dominican
Turkey 13 3 Suez 3
Republic
Vietnam 13 Georgia 3 Tokyo 3
2
Colombia 12 Israel 3 Ulsan 3
Mexico 12 Kuwait 3
1 Venice 3
Thailand 12 Madagascar 3
Wakayama 3
0 Malaysia 11 Mozambique 3
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Yangtze River 3
Venezuela 10 Qatar 3
Yemen 3 Zhangjiagang 3
R E P O R T O N P & I C L A I M S I N V O LV I N G V E S S E L S U N D E R P I L O T A G E 1 9 9 9 - 2 0 1 9 30 / 31

The year with the greatest

frequency was 2014 in
Singapore when there were
The timeline of incidents for the top four ports in Table 8 has been
7 incidents, the majority of
examined. No particular trend is evident in any of these ports. The
which (4) were collisions with incidents in Houston, Singapore, Antwerp and New Orleans occurred
other vessels. This no doubt in 14, 10, 13, and 7 separate underwriting years respectively. In 28 of
reflects the traffic density those years there was only one incident. The year with the greatest
at that port frequency was 2014 in Singapore when there were 7 incidents, the
majority of which (4) were collisions with other vessels. This no doubt
reflects the traffic density at that port.

EUROPE
NORTH AMERICA
194
202
INCIDENTS
INCIDENTS

ASIA
365
INCIDENTS
AFRICA
119
INCIDENTS
OCEANIA
SOUTH AMERICA
21
106
INCIDENTS
INCIDENTS

The map above is self-explanatory and required no comment.

R E P O R T O N P & I C L A I M S I N V O LV I N G V E S S E L S U N D E R P I L O T A G E 1 9 9 9 - 2 0 1 9 32 / 33

COMMENTARY ON CAUSATION
AND RECOMMENDATIONS

COMMENTARY It is difficult to draw any specific conclusions on the causes of these

incidents because in the majority of the records there is no narrative of events
or analysis of the root cause of each incident. As a result, the conclusions and

ON CAUSATION AND recommendations in this report are necessarily determined on a generic basis.
Whilst the number and overall cost of the incidents covered by this report

RECOMMENDATIONS
are significant, some context is necessary. When viewed with reference to the
number of shipping movements in and out of port worldwide in any one year, the
frequency of these incidents is extremely low. It has been difficult to obtain data
on worldwide ship movements under pilotage, but information published by
UNCTAD provides the following figures for ship arrivals in port in 2018:

WORLDWIDE SHIP ARRIVALS IN 2018 (SOURCE UNCTAD)

SHIP TYPE NUMBER OF ARRIVALS

All ship arrivals 4,112,944

Passenger 2,227,407
Wet bulk 494,120
Container 454,016
Dry breakbulk 430,344
Dry bulk 259,551
RoRo 187,532
LPG 49,357
LNG 10,617

It is likely that the passenger vessel arrivals will comprise a large number of ferries which are unlikely
to need or use pilots. The other vessel types in the table are those which will be more likely to need
the services of a pilot and hence fall within the ambit of this report.

The number of arrivals in 2018 for those vessel types totals 1,885,537. If it is assumed that there may
be 10% of those for which a pilotage exemption may exist, that reduces the figure to 1,696,983 –
say 1,700,000. If each arrival has a consequential departure this would then mean that there could
be something in the region of 3.4m ship movements under pilotage per annum. The figure could be
higher if movements under pilotage to anchorage prior to arrival were to be included.

In 2018 there were 30 incidents covered by this report. That is an infinitesimally small percentage
of the estimated total number of pilotage moves in that year. This therefore demonstrates that
the vast majority of ship moves under pilotage proceed uneventfully, and this is a tribute to
the professionalism, experience and skill of the world’s maritime pilots. On occasion however,
pilotage operations do not proceed as intended and the consequences can be severe
as this report establishes.
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ICS PILOTAGE TOWAGE AND MOORING SURVEY

In 2016 the International Chamber of Shipping commissioned a survey on Pilotage

ICS PILOTAGE
Towage and Mooring and the results of that were included in a submission to the IMO’s
Sub-Committee on Navigation Communications and Search and Rescue in December
2017 (NCSR 5/INF.8). That submission is included with this report as Annex I.

TOWAGE AND The ICS survey covered 472 ports in 123 countries and its findings were based upon
879 responses, predominantly from masters and Officers of the Watch. The outcome
of this survey produced, inter alia, the following results:

MOORING SURVEY
SATISFACTION RATE

84% 82% 72% 78%

CONDUCT CONDUCT OF USE OF ELECTRONIC TOWING AND
NAVIGATIONAL AIDS
OF PILOT PILOTAGE MOORING

The findings listed below are also worthy of note:

Communication difficulties between pilots and bridge

teams is a commonly reported concern worldwide.

It is understandable that communications between the pilot, towage

and mooring personnel are often conducted in a local language.
However, this practice places a burden on the pilot (that may
interfere with the pilot’s primary role) to translate orders and
actions during towage and mooring.

There may be the need for the development of an internationally

standardised approach to the Master-Pilot Information Exchange
(MPX) which emphasises the visual presentation of the pilot’s
plan for the pilotage during the MPX and discourages reliance
upon a purely verbal exchange of information.

The findings of the survey were shared with the International Maritime
Pilots Association (IMPA). IMPA were not surprised by the report’s
endorsement of the good work undertaken by their members, nor
by the uneven quality of the MPX and Bridge Resource Management
(BRM) that is encountered by their members. To demonstrate their
commitment to improvement, IMPA issued guidance documents to
assist their members on the issues of BRM training for pilots and MPX
and launched a collaborative poster campaign with the Marine
Accident Investigators International Forum (MAIIF) – see Annex II.
IMPA have emphasised however that in order to maximise the
benefits from these efforts it is essential for there to be full
engagement of masters and officers in pilotage operations.
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BRIDGE RESOURCE MANAGEMENT (BRM)

In its document on Recommendation for Bridge Resource Management

BRIDGE RESOURCE
courses for pilots, in drawing the distinction between the courses required
for ships’ officers to whom standardised routines and procedures apply,
and those required for pilots, IMPA made the following observations

MANAGEMENT (BRM)
concerning the specific challenges that pilots face on a daily basis:

“On each assignment, a compulsory pilot will typically encounter a different ship, different
bridge equipment and lay-out, a different operating environment, a different set of navigation
procedures, and a different crew (usually one with limited English language abilities) with varying
Following on from IMPA’s comments above on BRM, it is often apparent when
skill levels and capabilities from what the pilot encountered on the previous assignment. In most
reviewing the circumstances of incidents generating P&I liabilities that have
pilotage areas, the compulsory pilot is also expected to exercise independent professional
arisen when vessels are under pilotage, that the BRM on the vessel has been judgement, which may on occasion conflict with the intentions of the ship’s operator or master.
sub-optimal. It is therefore well recognised that it is to the benefit of all in any Because of those circumstances, pilots need to assess quickly the nature and quality of the
passage under pilotage that the external pilot and the vessel’s bridge team resources available for each pilotage assignment and then adjust their practices to get the
function as an effective and cohesive unit. This can be challenging to achieve. most out of those available resources. This calls for flexibility and adaptability rather than rigid
adherence to a standardised routine.”

Much has been written over the years on this general issue of
optimising the performance of bridge teams and pilots. In 1983 OCIMF,
ICS and INTERTANKO published the booklet “International Best Practices
for Maritime Pilotage”. The guidance in that document is as relevant
today as it was 37 years ago. This perhaps emphasises the need for
continued attention to, and reinforcement of those best practices
to help reduce the number of avoidable incidents.

It has also been noted that an updated version of the ICS Bridge
Procedures Guide (BPG) will be published in 2021 and will include:

A new section on BRM, with examples of best practices

and bridge team integration,

A revamp of the MPX with the assistance of IMPA, and

A revised and updated chapter on Pilotage.

When the new guide is launched, the ICS will be heading up

a pilot ladder compliance drive in tandem with IMPA.

There are several areas of P&I liability exposure, for example entry
to enclosed spaces, accidents involving lifeboats etc., where the
underlying risk is long established, well recognised and the subject
of persistent training, and yet the risk continues to be the cause of
repeated casualties. The appropriate response is enhanced and
repeated training to ensure that best practices become embedded
and thus more likely to be adhered to.

In the context of casualties arising under pilotage, absent a

radical and novel solution – and none is immediately apparent -
the enhanced and repeated training response outlined above
is equally appropriate to that situation.
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BRIDGE RESOURCE MANAGEMENT (BRM)

Such training, whether in a formal training establishment setting, In 2018 IMPA undertook a survey There is frequently a very limited amount of time between the
or in the less formal arrangement of company training sessions of the safety of pilot boarding pilot arriving on the bridge, the MPX taking place, and the ship
for its officers, is also likely to be enhanced by the participation in arrangements and received returns commencing its approach to the port. For a crew that may never
those training sessions of either serving or very recently retired pilots. from over 4,300 participating IMPA previously have visited that port this may then mean it is difficult for
members worldwide. There were the bridge team to effectively assimilate all the requirements of the
This training should place emphasis upon matters such as:
570 returns (over 13%) reporting passage plan from the pilot station to the berth. If more ports were
boarding arrangements that were to provide on their websites generic diagrams and instructions on
Proper and diligent MPX, and ensuring that pilots are fully
not in compliance with the how ships are usually piloted both inbound and outbound, this would
informed about any limitations of the vessel’s machinery or
requirements of SOLAS Regulation provide an opportunity for masters and navigating officers to study
equipment - e.g. engine power, steering, bitt capacity etc.
V/23 and IMO Resolution 1045/27 – and understand the outline requirements prior to the vessel’s arrival
Understanding all aspects of the voyage plan for the see the following weblink: at the pilot station. This would also facilitate the preparation on the
passage under pilotage. vessel of more accurate berth to berth passage plans. This could also
https://ukmpa.org/wp-content/
serve to alleviate time pressure during the MPX. Where such generic
The need for vigilance on the part of ships’ officers in monitoring uploads/2018/11/impasafety-
plans were available, the MPX could focus upon any deviation from
the progress of the vessel with reference to that plan. brochure-2018pagesfinalprint.pdf
the generic plan that might be necessary because of particular local
Officers raising awareness immediately any deviation The importance of compliance with circumstances at that time.
from the passage plan is noted these requirements cannot be over
emphasised if the safety of pilots
Communication with the pilot – especially when there are doubts.
during the process of boarding is to
Encouraging officers to question a pilot where there is any be assured. By ensuring that a pilot
uncertainty about the situation, or the actions intended and boards a vessel under safe conditions
understanding the most effective way in which to do this. and is then met and escorted to PILOT LIABILITY AND INSURANCE
Reinforcing the understanding of masters that, with the sole the bridge by a responsible officer,
Whenever incidents occur that result in in substantial P&I liabilities,
exception of the Panama Canal, the pilot directs the navigation a master can have much greater
it is understandable in such situations that the question arises of
of the ship, supported by the bridge team. The master remains confidence that the pilot will be
whether there is any liability on the part of the pilot or the relevant
in command and has the right, and indeed the duty, to intervene in a settled frame of mind to
pilotage body, and whether insurance coverage for such liability exists.
if it should be felt that the actions of a pilot endanger the safety commence his or her duties
The position varies according to jurisdiction but it is commonly the case,
of the ship. immediately and effectively.
as indicated above, that the pilot has the conduct of the navigation
With the exception of cruise ships, and the shipowner remains vicariously responsible for liabilities arising
It is also important to reinforce the understanding of masters that there is limited opportunity for the from the pilots’ acts or negligence. There are jurisdictions in which the
even when the vessel has the assistance of a pilot, they are ultimately majority of masters to experience the potential for recourse against the pilot or pilotage body is possible.
responsible for the safety of their vessel, its crew the environment and handling and manoeuvring of their For example in Italy there is now legislation which imposes liability on
its cargo and that they should not allow commercial or other pressures own vessels in confined waters. In pilots up to a maximum of €1m and requires compulsory insurance.
to compromise safety.
...masters are ultimately the area of training therefore, there More generally however, even where recourse is possible, the potential

In response generally to casualties that have a navigational cause,

responsible for the safety is perhaps also benefit in providing levels of financial liability are often low and such liability may not be
greater opportunities for masters and covered by insurance. The idea therefore of addressing the concerns
navigational audits or reviews have assumed greater significance of their vessel, its crew senior officers to gain experience that prompted this report through widespread legislative change and
in recent years as a tool to aid loss prevention. There are benefits
the environment and its of manoeuvring their vessels at slow associated insurance regimes is considered unrealistic. There would
to be gained from more frequent reviews of bridge team navigational
performance whilst vessels are under pilotage, undertaken by cargo and they should speed in order to improve their be a cost burden that would inevitably affect every ship movement
understanding of how the vessel under pilotage, the overwhelming majority of which proceed without
companies’ marine superintendents with navigational review not allow commercial responds to helm and engine orders incident. Further the scale of change that might be achieved and the
training and experience, or independent consultants in this field.
or other pressures to in various conditions of draught and level of financial recovery is unlikely to result in a significant impact. It is
One key ingredient to the establishment of an effective bridge team when subject to the effects of wind considered that the better approach is to focus upon the prevention of
when under pilotage is the creation of a good working relationship
compromise safety and current. incidents through a collaborative approach on incident investigation.
with the pilot from the outset. The pilot’s relationship with those on the
vessel they have been rostered to assist begins during the process of
boarding. That is a hazardous operation with an ever-present and
real risk of personal injury to the pilot.
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CONCLUSION –
RESPONSE TO INCIDENTS

CONCLUSION
It is inevitable that there will continue to be incidents of loss or
damage that arise with vessels under pilotage. However, one
can only hope that the measures outlined in this report might

RESPONSE TO
serve to reduce the frequency and severity of these. However,
when such incidents occur it will be beneficial for there to be
more specific follow-up action than generally occurs now.

INCIDENTS Not all incidents will be the subject of a published flag state investigation
report. Because these incidents, particularly Allision/FFO generally involve
strict liability on the part of the vessel, the focus of the claims handler at
the P&I Club involved will be upon mitigating the financial consequences
of the casualty, and not necessarily on determining what went wrong,
and what actions or recommendations might be made to reduce the
risk of recurrence. More attention on this area is recommended.

In those instances where no flag state investigation will be made, some

structure needs to be established that will facilitate fact-finding, root cause
analysis and risk mitigation measures for more costly incidents, or those
where more egregious conduct is evident. Perhaps a Memorandum of
Understanding (MoU) approach under which there is a commitment to
cooperate with the IG Clubs on the part of the more significant pilotage
bodies, hopefully with the support of IMPA, in investigating the causes of
more serious incidents for the purpose of identifying measures that will
assist in preventing further loss. Such MoUs should provide for:

joint incident investigations leading to establishing meaningful

root causes,

a platform to co-operate in formulating lessons learnt without

appointing blame, and

tracking the implementation of mitigating measures in the long term.

If that recommendation is accepted, further work will be necessary to

draft the terms of a MoU and identify the principal entities who should
be approached with this initiative. This work might usefully start with the
pilotage bodies involved with the most serious container vessel/gantry
crane incidents to which reference is made on page 11 of this report.
It should also be noted that IMPA has been closely following the incidents
involving large container ships and has made submissions on this topic
to the IMO’s Sub-Committee on Implementation of IMO Instruments.
These seek an expert review of relevant Marine Safety Investigation
Reports on such incidents with a view to identifying measures that
will improve operational safety and enhance safe berthing procedures.
See submission III 6/4/4 dated 25 April 2019 – Annex III.

Another area of initial focus could also be the Suez Canal Authority
given the frequency of groundings in that waterway.
R E P O R T O N P & I C L A I M S I N V O LV I N G V E S S E L S U N D E R P I L O T A G E 1 9 9 9 - 2 0 1 9

ANNEXES
ANNEX I – NSCR SUBMISSION 43

SUB-COMMITTEE ON NAVIGATION, NCSR 5/INF.18

COMMUNICATIONS AND SEARCH AND 15 December 2017
RESCUE ENGLISH ONLY
5th session
Agenda item 22

ANY OTHER BUSINESS

Results of the ICS pilotage, towage and mooring survey 2016

Submitted by the International Chamber of Shipping (ICS)

SUMMARY

Executive summary: This document provides the results of a pilotage, towage and
mooring survey conducted by ICS between 16 September 2016
and 16 November 2016
Strategic direction: No related provisions

High-level action:

Output: No related provisions

Action to be taken: Paragraph 9

Related documents: Resolution A.960(23) and FAL.6/Circ.11/Rev.1

Introduction

1 This document provides the executive summary of the report of the results of an ICS
pilotage, towage and mooring survey (the Survey) conducted between 16 September 2016
and 16 November 2016. The questionnaire was completed for 903 port calls during the survey
period.

2 The Survey was conducted at the request of the Members of ICS in order to review
the performance of pilotage, towage and mooring services worldwide. The questionnaire was
developed using operational knowledge and experience, best practice guidance in the ICS
Bridge Procedures Guide (5th edition) and the:

.1 Recommendations on training and certification and operational procedures

for maritime pilots other than deep-sea pilots (resolution A.960(23)); and

.2 Guidelines on minimum training and education of mooring personnel

(FAL.6/Circ.11/Rev.1).

I:\NCSR\05\NCSR 5-INF.18.docx
ANNEX I – NSCR SUBMISSION 44

NCSR 5/INF.18
Page 2

Executive summary

3 The survey reports the level of satisfaction of masters and bridge teams with pilotage,
towage and mooring services. This results should be considered in context and be used as a
benchmark for reviewing changes in satisfaction that may be observed should the survey be
repeated in the future.

Satisfaction rate (%)

Conduct of the Pilot 84
Conduct of the pilotage 82
Use of electronic navigation aids 72
Towage and mooring services 78

4 Based on the responses received, the quality of pilotage, towage and mooring
services worldwide have generally been reported to be of a satisfactory standard and, in
particular:

.1 the survey identified no systemic concerns with respect to the content and
application of the Recommendation on training and certification of maritime
pilots other than deep-sea pilots (resolution A.960(23), annex 1);

.2 the survey identified no systemic concerns with respect to the content and
application of the Recommendation on operational procedures for maritime
pilots other than deep-sea pilots (resolution A.960(23), annex 2); and

.3 the survey identified no systemic concerns with respect to the provision of

towage, mooring services or the Guidelines on minimum training and
education of mooring personnel (FAL.6/Circ.11/Rev.1).

5 Despite the general level of satisfaction reported in paragraph 4 above, the following
safety related findings from the survey are worthy of note:

.1 communication difficulties between pilots and bridge teams is a commonly

reported concern worldwide;

.2 the level of knowledge of the areas of the recommended syllabus for pilotage
and certification or licensing contained in section 7 of annex 1 of resolution
A.960(23) which were addressed in this survey demonstrated concerning
inadequacies by a minority of pilots;

.3 the availability and use of personal protective equipment (PPE) by pilots and
the provision of appropriate vessels for Pilot transfer is an area of concern.
In the case of PPE, there were 36 reports covering 16 different countries of
pilots boarding without appropriate PPE;

.4 it is understandable that communications between the Pilot, towage and

mooring personnel are often conducted in a local language. However, this
practice places a burden on the Pilot (that may interfere with the Pilot's
primary role), to translate orders and actions during towage and mooring;
and

.5 there may be a need for the development of an internationally standardized

approach to the Master-Pilot information exchange (MPX) which emphasizes
the visual presentation of the Pilot's plan for the pilotage during the MPX, and
discourages reliance on a purely verbal exchange of information.

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6 Given the findings in paragraphs 5, particularly paragraph 5.3, the outcome of the
survey has been shared with the International Maritime pilots Association (IMPA).

Results of the Survey

7 The results of the Survey are provided in annex 1 to this document. Whilst responses
to the survey included references to specific ports and countries, these have been removed
from the results presented here. The Survey questionnaire is provided at annex 2.

Future of the Survey

8 The Survey may be repeated at an appropriate point in the future, but it will not be
conducted on an annual basis.

Action requested of the Sub-Committee

9 The Sub-Committee is invited note the information provided.

***

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ANNEX 1

RESULTS OF THE ICS PILOTAGE, TOWAGE AND MOORING SURVEY 2016

1.1 Number of responses. Of the 903 responses, 879 were considered valid.
The following responses were excluded from the analysis of the results:

 Incomplete and unusable responses1; and

 Responses from pilots.2

1.2 Who completed the survey?

The Company Other (28)

(19)

An OOW
(152)

The Master
(684)

Other (2) Cadet (1)

Master & Chief
Officer (1)
Chief Officer
(1)

Bridge
Deputy Team (10)
Captain (6)

Master & OOW

(7)

1.3 Port coverage. The survey was completed for 472 ports in 123 different
countries. 97.95% (861) of responses were for a port call where a Pilot was embarked. In these
cases, all questions regarding pilotage, towage and mooring (questions 5 to 11) were
completed. The remaining 2.05% (18) of responses covered port calls where no Pilot was
embarked. In these cases only the questions relating to towage and mooring (questions 9
to 11) were completed.

1.4 Pilotage Exemption Certificates (PEC). The questions in this section of the survey
related to the availability of PECs and the existence of clear procedures for the application and
validation of PECs by port authorities.

1
The submission of incomplete responses explains the variations in total responses for particular questions.
2
This information has however been kept as it generally provides more detailed comments on towage and
mooring services provided at some ports.

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1.4.1 PECs were not available in 89.2% of ports for the ship type of the
respondents covered by the survey. Where PECs were available in 81 of the
ports covered in the survey. In those 81 ports, 70 (86.42%) had clear
application and validation procedures.

1.4.2 No notable findings were obtained from analysis of responses to questions

concerning the availability of PECs.

1.5 Conduct of the Pilot. The questions in this section were, in general, based on the
recommendations for operational procedures for pilots contained in annex 2 to IMO resolution
A.960(23).

1.5.1 In general, the Master-Pilot Information Exchange (MPX) and associated

checklists are being used effectively to ensure that the Pilot and Bridge Team
are fully informed prior to pilotage commencing;

1.5.2 The volume and form of information exchanged during the MPX is
inconsistent. Varying from an entirely verbal exchange of information to a
comprehensive briefing supported by checklists and passage plans (of the
ship and the Pilot);

1.5.3 In 36 cases respondents reported a failure of pilots to follow appropriate

procedures or use appropriate PPE, particularly lifejackets, when embarking.
This issue affected ports in 16 countries;

1.5.4 The locations of pilot boarding points (as charted) and locations of actual
point of pilot embarkation can vary significantly and may bring ships to well
within pilotage waters. This finding is contrary to the recommendations in
section 3.3 and section 5.5 of IMO resolution A.960(23);

1.5.5 Observations were made of requests for last minute changes to Pilot
boarding arrangements, including the requirement to rig accommodation
ladders in place of Pilot ladders even when the climb is less than 9m;

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1.5.6 Observations were made of a lack of availability of appropriate Pilot vessels.

Reports of the use of tug rescue boats and small dinghies being used for
Pilot transfers;

1.5.7 There remains scope of an internationally recognized and accepted

approach to the delivery of the MPX;

1.5.8 In some responses, significant concerns were raised regarding corrupt

practices engaged in by some pilots;

1.5.9 Observations were made that the MPX was conducted entirely verbally and
without support of a checklist or passage plan. This was a particular matter
of concern in ports in 4 countries;

1.5.10 Observations were made that pilots had limited knowledge of bridge resource
management (BRM) and that ensuring that a chain of errors did not develop
was left to the Bridge Team; and

1.5.11 Concerns over the quality of English used by pilots was a general concern
expressed by Masters and Bridge Teams in a number of countries.

1.6 Conduct of the pilotage. The questions in this section were based on section 5.5 of
Recommendations on training and certification of maritime pilots other than deep-sea pilots
(IMO resolution A.960(23), annex 1).

1.6.1 In general, respondents commented positively on the experience, knowledge

and abilities of pilots and the conduct of pilotage was in accordance with IMO
resolution A.960(23);

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1.6.2 Observations were made regarding the familiarity of pilots with the latest
propulsion technologies, particularly electronically controlled engines, and
the impact of this on use of main engines during berthing and un-berthing;

1.6.3 Observations were made that the knowledge of the Master and Bridge Team
regarding the capabilities of propulsion systems and ships manoeuvring
behaviour should be given greater consideration during berthing and
un berthing operations;

1.6.4 Observations were made that the flow of information between the Bridge
Team and Pilot required encouragement from the Bridge Team to discuss
actions in accordance with the COLREGs, instructions from port control, and
use and positioning of tugs; and

1.6.5 Observations were made that, in general, Pilot's appreciation of risk is

satisfactory. Only in a small number of locations in 3 countries were there
reports of that the Pilot's appetite for risk was considered incompatible with
the Master's.

1.7 Electronic Navigation Aids.

1.7.1 In general, knowledge and appropriate use of electronic navigation aids,

particularly ECDIS was satisfactory, reflecting section 7 of annex 1 to with
IMO resolution A.960(23);

1.7.2 Although observations were made regarding over-reliance on personal Pilot

units (PPU), in the majority of cases good practices involving multiple
sources of information were used for decision making with subsequent
actions explained to the Bridge Team to enable them to continue to monitor
safety effectively; and

1.7.3 Observations were made that pilots are not familiar with ECDIS and are
unwilling to use ECDIS during pilotage, even on ships which navigate using
ECDIS.

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1.8 Pilotage Incidents or Near Misses (Current Port Call).

1.8.1 During the survey period, 30 responses (4%) included pilotage incidents or
near misses with a Pilot embarked. The below assessment uses PivotTables
to focus on assessing the potential relationship between the relevant
responses to Question 5 and Question 6. The term "negative" means a
combined total of "disagree" or "strongly disagree" responses. The term
"positive" means a combined total of "agree" and "strongly agree" responses.
Differences in total figures reflects the incompleteness of some
questionnaires

1.8.2 For the MPX (Question 5.2):

Incident or Near Miss Negative Positive Total

No 23 787 810
Yes 7 23 30
Total 30 810 840

1.8.3 For cooperation and bridge resource management (Question 5.3):

Incident or Near Miss Negative Positive Total

No 18 792 810
Yes 9 20 29
Total 27 812 839

1.8.4 For communication (Question 5.4):

Incident or Near Miss Negative Positive Total

No 31 782 813
Yes 8 22 30
Total 39 804 843

1.8.5 The data indicates that there is no apparent causal relationship between a
negative assessment of any of the factors for conduct of the Pilot and
conduct of the pilotage and a report of an incident and near miss.
This indicates that the incidents or near misses reported were influenced by
a factor or factors other than those addressed in this survey.

1.9 Towage and Mooring. The questions relating to towage and mooring were based on
the best practice guidance provided in the 5th Edition of the ICS Bridge Procedures Guide,
consultation with ICS Members and the guidelines on minimum training and education of
mooring personnel (FAL.6/Circ.11/Rev.1).

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1.9.1 In general, the provision of towage and mooring services was considered
satisfactory by respondents. However, the principle area for concern is the
burden placed on the Pilot by the need to translate communications between
the Pilot, tug master and shore-based mooring personnel at a critical time;

1.9.2 Observations were made in ports in 5 countries that cooperation between

mooring personnel and the Pilot and/or ship's mooring personnel is not
always effective.

1.9.3 Observations regarding the absence of personal protective equipment (PPE)

for mooring personnel were made in one country;

1.9.4 Observations were made of inadequate numbers of mooring personnel being

available to support safe mooring;

1.9.5 Port regulations did not always take into account the manoeuvrability of
ships, for example by requiring a specific number of tugs, rather than a
number of tugs appropriate to the vessel, it characteristics and conditions at
the berth; and

1.9.6 Observations were made of a practice in one country where the language
barrier between Bridge Team and mooring personnel is addressed through
the use of a pre-agreed mooring plan and the use of visual signals.

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1.10 Towage and Mooring Incidents or Near Misses (Current Port Call).

1.10.1 During the survey period, 21 incidents or near misses during towage
operations and 31 incidents or near misses during mooring operations.
The assessment below uses PivotTables to focus on the assessing the
potential relationship between incidents and near misses and the relevant
responses to Question 9. The term "negative" means a combined total of
"disagree" or "strongly disagree" responses. The term "positive" means a
combined total of "agree" and "strongly agree" responses. Differences in total
figures reflects the incompleteness of some questionnaires.

1.10.2 For appropriate tug selection:

Incident or Near Miss Negative Positive Total

No 29 773 802
Yes 2 19 21
Total 31 792 823

1.10.3 For towage addressed in the MPX:

Incident or Near Miss Negative Positive Total

No 30 770 800
Yes 2 19 21
Total 32 789 821

1.10.4 For tugs supporting a safe and efficient mooring operation:

Incident or Near Miss Negative Positive Total

No 36 752 788
Yes 3 18 21
Total 39 770 809

1.10.5 For positioning and use of tugs during mooring operations:

Incident or Near Miss Negative Positive Total

No 70 721 791
Yes 4 17 21
Total 74 738 812

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1.10.6 For shore-based mooring personnel and mooring boats supporting a safe
and efficient mooring operation:

Incident or Near Miss Negative Positive Total

No 41 767 808
Yes 3 30 33
Total 44 797 841

1.10.7 For communications during mooring operations:

Incident or Near Miss Negative Positive Total

No 267 545 812
Yes 11 21 32
Total 278 566 844

1.10.8 For attendance until mooring operation completed:

Incident or Near Miss Negative Positive Total

No 45 761 806
Yes 1 32 33
Total 46 793 839

1.10.9 The data indicates that there is no apparent causal relationship between a
negative assessment of any aspect of the towage or mooring operations and
a report of an incident and near miss. This indicates that the incidents or near
misses reported were influenced by a factor or factors other than those
addressed in this survey.

1.11 Incidents or Near Misses (Port calls in last 12 months). Respondents to the survey
accumulated 5057 port calls at the ports covered by the survey in the 12 months preceding the
survey. Over this 12-month period, 3.2% (162) port calls involved an incident or near miss
during either pilotage, towage or mooring operations.

***

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ANNEX 2

SURVEY QUESTIONNAIRE

1. This survey was completed by: * (Required Field)

A Master
An OOW
The Company
Other (Please specify)

2. Port or Terminal: * (Required Field)

Please provide the full name of the Port or Terminal.

3. Was a Pilot Embarked? * (Required Field)

Yes

No

4. Pilotage Exemption Certificates (PEC) (One answer per row)

Yes No
A PEC is available from the Port Authority, for appropriately qualified deck
officers

There is a formal and transparent application process for a PEC

The PEC assessment process, including renewals, is fair, proportionate

and transparent

Comments:

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5. Conduct of the Pilot (One answer per row)

Strongly Strongly
Agree Disagree
Agree Disagree
The Pilot followed safe embarkation and
disembarkation procedures and used
appropriate PPE

An effective Master-Pilot Information

Exchange (MPX) was conducted using
an appropriate supporting checklist

The Pilot cooperated with the Master

and Bridge Team and made use of the
principles of Bridge Resource
Management (BRM)

The Pilot communicated their

knowledge effectively to the Master and
Bridge Team, in a common working
language or English and using the IMO
Standard Maritime Communications
Phrases (SMCP) as appropriate

Comments:

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6. Conduct of the Pilotage (One answer per row)

The Pilot demonstrated detailed local knowledge and skill which enhanced the safety of
navigation in pilotage waters, including:

Strongly Strongly
Agree Disagree
Agree Disagree
Identification, position and
characteristics of aids to navigation

Names and characteristics of channels,

shoals, headlands and other points

Depths of water and tidal conditions

and effects

Locations of hazards to navigation

Bridge and under keel clearances

Proper courses and distances of

pilotage legs

Location of anchorages

Effective anti-collision advice in

accordance with the COLREGS, taking
into account knowledge of local traffic
patterns

Effects of environmental conditions,

including interaction effects on ship
performance

Manoeuvring behaviour of the ship and

the limitations imposed by particular
propulsion and steering systems

Ship handling, including safe

approaches and departure from the
berth and manoeuvring with and
without tugs

Comments:

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7. Electronic Navigation Aids (One answer per row)

Strongly Strongly
Agree Disagree
Agree Disagree
The Pilot was familiar with electronic
navigation aids, including ECDIS

Bridge navigation equipment was used

to support decision making by the Pilot
and Bridge Team

The Pilot relied on a Personal Pilot Unit

(PPU) for decision making

Comments:

8. Pilotage Incidents or Near Misses

During THIS port or terminal call, did the ship experience a safety and/or
environmental incident or near miss during pilotage with a pilot embarked?

Yes

No

Not applicable

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9. Towage and Mooring Services (One answer per row)

Strongly Strongly
Agree Disagree
Agree Disagree
The number and size of tugs provided
for towage during mooring operations
was adequate for the size of vessel and
berthing conditions

Towage during mooring operations was

included in the Master-Pilot Information
Exchange (MPX)

Tugs complied with the instructions of

the Master or Pilot and effectively
supported a safe and efficient mooring
operation

The Master and Bridge Team were kept

informed of changes in the positioning
and use of tugs during mooring
operations

Shore-side mooring personnel and

mooring boats complied with the
instructions of the Master or Pilot and
effectively supported a safe and
efficient mooring operation

Communications between the Pilot,

tugs and mooring personnel were
conducted in a common working
language and were clearly understood
by the Master and Bridge Team

Shore-based mooring personnel did not

break communications before mooring
operations was complete

Comments:

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10. Mooring and Towage Incidents or Near Misses

During THIS port or terminal call, did the ship experience a safety and/or
environmental incident or near miss during towage or mooring operations?

Yes No
During towage

During mooring

11. Incidents and Near Misses in the last 12 Months

If the Ship REGULARLY calls at the port or terminal, has it experienced a safety and/or
environmental incident or near miss in the last 12 months?

Number of calls at the port or terminal

Number during pilotage with a pilot embarked

Number during towage operations

Number during mooring operations

___________

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A N N E X I I – I M PA C O L L A B O R A T I V E P O S T E R C A M PA I G N W I T H T H E M A R I N E A C C I D E N T I N V E S T I G A T O R S I N T E R N A T I O N A L F O R U M ( M A I I F ) 60

Commit to Safe Navigation

SAFE NAVIGATION IN PILOTAGE WATERS IS A SHARED TASK

OF THE BRIDGE TEAM AND THE PILOT

SHARE NAVIGATION INFORMATION

RESPECT EACH OTHER
COMMUNICATE THROUGHOUT THE VOYAGE
WORK TOGETHER
STAY ALERT
ANNEX III – III 6-4-4 SUBMISSION 61

SUB-COMMITTEE ON IMPLEMENTATION III 6/4/4

OF IMO INSTRUMENTS 25 April 2019
6th session Original: ENGLISH
Agenda item 4 Pre-session public release: ☒

LESSONS LEARNED AND SAFETY ISSUES IDENTIFIED FROM THE ANALYSIS

OF MARINE SAFETY INVESTIGATION REPORTS

Safe pilotage practice

Submitted by the International Maritime Pilots' Association (IMPA)

SUMMARY

Executive summary: This document comments on and provides an overview on lessons

learned and safety issues identified from the analysis of marine
safety investigation reports regarding recent incidents involving ultra
large containerships (ULCSs) whilst under pilotage

Strategic direction, 6
if applicable:

Output: 6.4

Action to be taken: Paragraph 8

Related document: Resolution A.960 (23), annex 2

Background

1 IMPA has been following closely certain incidents involving ultra large containerships
(ULCSs) in port/pilotage areas, which have resulted in injury to port workers and included
damage to the ship, port and cargo-handling infrastructure.

The way forward

2 Section 5 of annex 2 of the Recommendations on Training and Certification and on

Operational Procedures for Maritime Pilots other than Deep-Sea Pilots (resolution A.960(23)),
relates to the master – pilot information exchange before the piloting/berthing procedure
commences.

3 Accordingly, as a first step, it is suggested that all pilotage authorities should ensure
that pilots are fully familiar with the recommendations outlined in annex 2 of
resolution A.960(23).

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III 6/4/4
Page 2

4 It is important for port and pilotage authorities to drive home the message to pilots
and ship operators on the imperative need for an exchange of information between the master
and the pilot and for the bridge team to take an active role in the ship's navigation in support
of the pilot.

5 The other practical issues that are of relevance are:

.1 inter-port rivalry for handling of ever larger ships may compromise safety
judgments and propose ships movements that involve excessive risk owing
to inadequate under keel clearance (UKC), channel width, safe turning
basins, or other necessary navigation infrastructure;

.2 machinery failure;

.3 rudders with small surface areas and software managed engines to improve
fuel economy make ship manoeuvring ever more difficult;

.4 absence and shortage of adequate number of assist tugs of suitable power

for the size of the ships being handled; and

.5 escort tugs and/or powerful tugs for steering/pushing a ship away from a
developing incident area.

6 From a closer review of a recent Marine Accident Investigation Branch (MAIB) report
of such incidents, some pertinent issues outlined above in paragraphs 5.1 to 5.5 relating to
operational pilotage/berthing matters are of relevance. In terms of planning and execution of
the ships' movement, there is always the important need for a master – pilot information
exchange (resolution A.960(23), annex 2, section 5) and for the bridge team to take an active
role in the ships' navigation in support of, and cooperation with, the pilot.

7 There is also a pressing need for coordination in management of pilotage and port
operations in respect of ULCSs. This is the norm in most major container ports. Impractical
Key Performance Indicators (KPIs) for pilotage/berthing movements and their corresponding
relationship to financial incentives can lead to unfortunate incidents/accidents.

Action requested of the Sub-Committee

8 The Sub-Committee is invited to take note and action as appropriate, taking into
consideration the following:

.1 IMPA is of the view that compliance with the very basic elements of safe
pilotage practice outlined above merit careful consideration including an
expert review by the Working Group on Analysis of Marine Safety
Investigation Reports, if established; and

.2 it is hoped that the relevant expert recommendations can then be shared as

deemed appropriate globally by IMPA with pilotage authorities to improve
operational safety and to enhance safe berthing procedures in ports.

___________

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Report on P&I claims involving
vessels under pilotage 1999-2019

For more information about the International Group, please visit our website
at www.igpandi.org or contact the International Group Secretariat:

International Group of P&I Clubs

78/79 Leadenhall Street, London, EC3A 3DH, UK

Tel: 00 (0)20 7929 3544

e-mail: [email protected]

www.igpandi.org