BALTIMORE, Md. (WAVY) – Inattention due to a pilot’s texting, making a series of phone calls and drafting an email was the root cause of the March grounding of a container ship that had been heading from Baltimore to Norfolk, the Coast Guard’s investigation report said.
Specifically, the report of investigation on the more-than-35-day grounding of the Hong Kong-flagged, 1,095.7-foot Ever Forward container ship “determined the incident’s casual factors to be the pilot’s failure to maintain situational awareness and attention while navigating, and inadequate bridge resource management.”
The vessel was eventually freed after dredging was completed to a 43-foot depth, resulting in 206,280 cubic yards of material dredged and having to remove 505 of the 4,964 containers from the vessel.
The executive summary of the report noted that “a licensed Maryland State Pilot … (was) in direction and control of the vessel,” and just prior to the grounding of the Hong Kong-flagged Ever Forward, he exited the active navigation of his portable pilot unit to view a previous transit.
“(Pilot 1) also made a series of five phone calls amounting to over 60 minutes of time during the course of his outbound transit,” the report stated. “He also sent two text messages and began drafting an email immediately before the grounding occurred regarding issues he experienced with facility line handlers.”
The time the pilot spent on his phone amounted to about half of the vessel’s two hour voyage, and the person was doing so right up until the incident took place. The pilot also admitted to relying solely on the portable pilot unit for navigation and was watching a playback of a previous transit when the vessel’s grounding took place.
“The Pilot was drafting an email on their personal cell phone in the minutes leading up to the planned turn south, when the vessel sailed through its waypoint and grounding,” the Coast Guard’s findings of concern on distracted operations stated. “The vessel’s bridge team attempted to cue the pilot by repeating the heading. However, by the time the bridge team became more assertive about the ship’s heading, it was too late to prevent the vessel from grounding.”
The Coast Guard determined that what initiated the issues with the vessel was its grounding.
“No mechanical issues or equipment failures contributed to this marine casualty,” according to the report. “The casual factors that contributed to this casualty include: (1) failure to maintain situational awareness and attention while navigating, and (2) inadequate bridge resource management.”
Immediately after the grounding, Coast Guard marine investigators started the investigation to determine how the Ever Forward ran aground and put together recommendations to prevent a similar event from happening in the future.
As a result of the incident, the Coast Guard is recommending that marine operators put forth, and put into place, effective policies as to when using smartphones and other portable electronic devices is appropriate or not allowed, the report stated. The Association of Maryland Pilots did not have a cell phone policy at the time of the incident.
It also called for vessel owners and operators to ensure and promote the crew’s awareness of policies as to the duties and obligations of officers on watch for the safety of the ship, even when a pilot is embarked.
The container ship left the Seagirt Marine Terminal in Baltimore around 6:12 p.m. March 13 and was heading to Norfolk – its departure time delayed due to challenges at berth securing the proper line handlers. The report noted no history of issues with the vessel’s portable pilot unit.
The pilot “was in the practice of intentionally not using any other navigational equipment while underway, citing a distrust of vessel equipment that was not his own and instances of equipment breaking while a pilot was using it.”
The pilot was unaware of paper charts available, and all vessel charts – both paper and electronic – were up-to-date.
The report has a minute-by-minute breakdown of the events before, during and after the grounding of the vessel, which took place outside of the Craighill Channel at 8:18 p.m. He and his crew tried to get the vessel moving, but within seven minutes, the ship’s Master gave orders to stop the engine and conduct safety checks.
The report’s analysis noted that Pilot 1 “was not actively engaged in navigating the vessel immediately prior to the grounding.”
Pilot 1’s phone calls took up about 1 hour and 1 minute of the vessel’s 2 hour, 6 minute voyage until the grounding, with the longest personal call taking more than 55 minutes, according to the report. He sent two text messages at 8:07 p.m. and 8:15 p.m. – a critical period according to the Coast Guard’s report, leading up to when the vessel’s turn south into the lower Craighill Channel should have taken place – and was observed looking at his phone again at 8:17 p.m., just one minute before the vessel ran aground.
They were able to verify, according to the report, that there was no pollution or water onboard. They also verified the type of seabed the vessel was grounded on – later verifying that it was made of mud and shells – and the Master got in touch with Evergreen Marine Corporation headquarters in Taipei, Taiwan and the local vessel representative to let them know it needed help.
The report also noted Pilot 1’s overreliance on the portable pilot unit.
“Pilot 1’s lack of awareness and decision not to use the ship’s charts, navigation aids and other available bridge navigation systems demonstrates an over-reliance on the singular PPU system … (which) limited the pilot’s ability to accurately and quickly make a full appraisal of the situation and safely navigate the vessel.
“Had Pilot 1 used all available means to determine the ship’s location, the grounding likely would not have occurred.”
The vessel’s bridge team, according to the report, also observed Pilot 1 “frequently on his cell phone” and “agitated,” but they hesitated telling Pilot 1 directly that the vessel had missed the waypoint to turn. And, the Third Officer was hesitant to question the pilot’s expertise and familiarity with the channel.
“Despite cultural differences or seniority, the Third Officer and others on the bridge should have been more assertive to let the pilot know the waypoint had been passed and turn missed,” the report stated. “Had the bridge team been more assertive and notified Pilot 1 of the missed turn, there may have been enough time to avoid or minimize the significance of the grounding.”
Pilot 1, the report said, had about 15 years of experience as a licensed Maryland State Pilot, with other officers and the Master of the vessel having between two to 15 years of experience in their respective roles.
The Coast Guard’s redacted copy of its report of investigation into the incident is available here. It said access to a full investigation and evidence would be available through the Freedom of Information Act process.
The Coast Guard also published two findings of concern – information related to unsafe conditions – and made them public. The Maryland Department of Labor, Division of Occupational and Professional Licensing, conducted an independent investigation and was able to access Coast Guard-collected evidence.
A unified command of the Coast Guard, Maryland Department of the Environment and Evergreen Marine Corporation, they developed and put into place a salvage plan to free the vessel, including dredging and towing operations.
The vessel was ultimately freed April 17.