Risk identification and mitigation in coastal pilotage operations is inadequate as a result of the under-reporting of risk events and incidents by pilots.
The ATSB acknowledges the action taken by AMSA to encourage safety action taken by the pilotage providers to address this safety issue through their safety management systems (SMS) in compliance with regulatory requirements. Australian Reef Pilots (ARP) has taken action that adequately addresses the safety issue for its operations. Torres Pilots (TP) has taken action that partially addresses the issue for its operations. Hydro Pilots (HP) has indicated that its SMS addresses this issue, that HP operates under a ‘just culture’ but provided no evidence. Based on the safety action taken by AMSA, ARP, TP and HP to date, the ATSB considers that the safety issue has been partially addressed. The continued development of provider SMSs and their effective implementation under AMSA’s regulatory oversight could adequately address the issue over time.
The Australian Transport Safety Bureau recommends that Australian Reef Pilots takes further action to facilitate action taken by the Australian Maritime Safety Authority to address the safety issue.
ARP disagrees that ARP has failed to effectively implement its no-blame reporting policy.
ARP has implemented the following measures to encourage reporting of risk events and incidents by pilots:
The restructuring and change of management within ARP has generated a company policy of safety reporting and actions first and to have no concerns for any commercial imperative second. The change to being employed instead of being a self-employed contractor has also removed any perceived personal disadvantage for pilots.
ARP has a dedicated Safety and Compliance Manager who maintains an incident register (see attached QSE MANAGEMENT SYSTEM - REGISTER OF NON-CONFORMANCES and sub NON-CONFORMANCES). The reports highlighted in yellow all concern pilots or were generated by pilots. No pilots have been punished as a result of these reports although in some cases ARP has provided additional training to the pilots concerned as the best means of corrective action.
ARP has an active safety committee which meets by teleconference monthly and has pilot representation.
Regular reinforcement of ARP’s incident reporting procedures (see attached Work Instruction 27 – Incident Reporting – Marine Incidents).
Australian Reef Pilots Pty Ltd is committed to continuous improvement of its safety management systems to ensure that we can continue to live up to our corporate motto “Guardians Of The Reef”.
The safety action taken by ARP together with the supporting evidence provided indicate that continued action should adequately address the safety issue for the company’s operations.
We have been working very hard to develop an organisational culture which encourages and rewards risk event reporting. Whilst this has been a challenging process, we are seeing positive results.
A recent example was a pilot fall from a pilot ladder. This event was promptly reported and ARP immediately invited ATSB to conduct an investigation. ARP has fully cooperated and awaits the investigation report in anticipation of applying lessons learned to improve our operations.
The safety action taken by ARP together with further supporting evidence provided indicates effective implementation of the action, which adequately addresses the safety issue for the company’s operations.
Hydro Pilots did not make a submission.
The Australian Transport Safety Bureau recommends that Hydro Pilots takes safety action to address the safety issue and facilitate action taken by the Australian Maritime Safety Authority to address this issue.
Hydro Pilots do not operate with a self-managed approach. Our Pilots work to a structured roster. Our Pilots work to a 20 day on 10 day off cycle. This roster has been implemented and agreed upon between all pilots and management.
In addition to this Hydro Pilots in conjunction with Torres Pilots Pty Ltd have recently submitted an alternative FRMP to AMSA. This plan has been developed with the assistance of sleep/fatigue experts Sally Fergusson and Mathew Thomas from the Appleton Institute of Adelaide. You will be aware that their input and expertise has also been sought by AMSA on the issue of fatigue within coastal pilotage.
The main purpose of the new FMP is to increase the frequency of pilot rostered leave and to increase the certainty of pilot time off roster. The proposed FMP will not increase Mackay resident pilot’s work commitments. It will provide those pilots with more certainty regarding their time at home by increasing the number of days they enjoy off roster, that is, the proposed FMP will allow the use of a more efficient roster and more planned time at home for the pilot.
The 10-day rest period allows for more frequent periods of long breaks from work, and as such is seen as an important mechanism in reducing the likelihood of cumulative fatigue. The plan also looks at Risk Identification and Assessment taking into account many factors. The plan is based on a “safety-case” approach which is what AMSA have requested.
With regard to the inclusion of pilot travel and transfer times this is not the case within our operations. Prior to commencement of pilotage a “Job Risk Analysis” is completed which look at many factors including the pilots previous rest to ensure that the 12 hour rest has been complied with. Upon completion of the pilotage our pilots provide our operations with the completed “certificate of pilotage” where the landing time back at Mackay is recorded as the completion time. Marine Pilots do not allocate themselves to ships. This is done by operations and is based on compliance with the current FRMP.
In response to the above I can refer back to my time with Torres Pilots Pty Ltd where all pilots were encouraged to report on any issues encountered on board vessels be they technical, safety or near miss incidents. All of these reports were documented and made freely available during every audit completed by AMSA.
On many occasions we were thanked by the operator of the vessel for the reporting of vessel deficiencies as these had not been reported by the Master back to his management.
In looking at Risk Identification HP will be adopting and managing risk through the implementation of processes currently followed by our aviation operations. On many occasions I have heard that we should look to the aviation industry and the processes that are followed there in regards to the mitigation of risk and improvement to safety. To this end HP will be utilizing a system and processes currently used within our aviation operations.
This system is well known to CASA and allows for safety reporting, risk identification, hazard register, hazard actions and follow up.
In addition to the above and prior to any pilotage the vessel is forwarded the passage plan which not only includes waypoints but also checks for parallel indexing, reporting obligations for REEFVTS, emergency contact information and cross tracks error limits for GPS entry. All pilots follow the same Pilot/Master exchange procedures. In essence we have uniformity in our approach to passage planning and associated documentation and reporting. All of the documentation for each completed pilotage is sighted and filed upon completion of the pilotage just as do within our aviation model.
AMSA conducted a follow up audit of our systems on Monday 14th January 2013. The above procedures were shown to the audit team and I was advised upon completion of the audit that the proposed implementation of this system would meet the requirements under Marine Orders Part 54.
We hope the above provides sufficient evidence in supporting the changes we have made and continue to implement within our SMS.
The safety action proposed by HP has the potential to adequately address the safety issue for the company’s operations.
Hydro Marine Pilots as part of the larger Aviator Group operate a 'Just Culture' to create a safe and fair workplace. The safety or our employees, customers and contractors are our number one priority. The safety and efficiency of our operations are mutually supportive and are achieved through a commitment to continuous improvement.
Under our Standard operating Procedures we clearly state the requirements for the reporting of incidents and hazards that could impact on navigation or the environment:
‘Incident and Reports during the Voyage
Pilots must be aware of and comply with all applicable laws, rules and regulations including relevant international conventions and any shipboard safety instructions. Pilots are obligated to report to the appropriate authority any concerns regarding any potential hazards to navigation or the environment. It should be noted that Australian legislation provides significant penalties for failing to comply with any reporting requirements.’
Hydro Marine Pilots support all pilots in encouraging the reporting of any event without fear of penalty. We do not support the assumption that the lack of reports is indicative of a poor safety culture. Unlike the other two pilotage providers, Hydro Marine Pilots only operate within the compulsory area of Hydrographers Passage. As a provider, we engage with our marine pilots face to face on a daily basis due to the location of our operations whereby our pilots are carried by our own helicopter. Discussions on the conduct of the pilotage are frequent with our marine pilots when they disembark the vessel. Our culture is one of inclusion with a shared responsibility for safety.
The ATSB acknowledges Hydro Pilots (HP) statement that the pilotage provider operates under a 'just culture', and that its procedures require pilots to report risk events, reiterate their reporting obligations and the regulatory penalties for failing to report. The provider’s frequent interaction with its pilots, as stated, can also promote a 'reporting culture'.
Hydro Pilots did not provide evidence, such as its risk event/hazard register, safety meetings, or other documents that indicate what, if any, risk events or hazards have been reported, discussed, or investigated. Further, HP's update did not refer to, or elaborate on, its intended approach to address the safety issue, as outlined in its previous response of 22 January 2013. In the absence of such information and evidence, ATSB's assessment is limited to re-stating that HP's stated commitment to addressing the safety issue has the potential to address the issue for the company’s operations.
Australian Reef Pilots advised the ATSB that it has a strong and consistent ‘no blame’ policy for incident reporting with no personal disadvantage to pilots reporting incidents. Australian Reef Pilots also advised that its management was in regular discussion with the Pilot Advisory Group, elected by the pilot body, to resolve matters of difference and indicated that it was engaged in dialogue with its contracted pilots regarding working and remuneration arrangements.
The ATSB acknowledges the action taken and proposed by Australian Reef Pilots but does not consider that it has effectively implemented its no-blame policy.
The Australian Transport Safety Bureau recommends that Torres Pilots takes safety action to address the safety issue and facilitate action taken by the Australian Maritime Safety Authority to address this issue.
2.1 Torres Pilots partially accepts and partially rejects the Reporting Safety Recommendation.
2.2 Torres Pilots accepts the recommendation to facilitate action taken by AMSA to address any perceived issues. To give effect to the recommendation, Torres Pilots:
(1) will continue to monitor compliance with the reporting requirements in MO 54, including the issue 5 amendments to MO 54
(2) will continue to promote a 'no blame' environment in Torres Pilots
(3) is engaged in developing a Risk Management Framework under advice from the Marine Consultancy Group
(4) is reviewing its SMS and working with its pilots on areas for improvement, those areas having been identified by senior pilots
(5) will continue to communicate with its pilots, encouraging them to report any safety concerns
(6) will continue to monitor and update its policies and SMS based on AMSA recommendations, amendments to MO 54 and industry best practice
(7) will encourage AMSA to adopt a no-blame environment for incident reporting.
2.3 Torres Pilots otherwise rejects the Reporting Safety Recommendation for the following reasons:
(1) Torres Pilots does not accept there are instances of under-reporting when it has not been provided with any details of the alleged incidents which have not been reported.
(2) There is no credible evidence presented in the report for supporting its conclusions. The findings of under-reporting are based on hearsay without any further detail of the specific occurrences which are alleged not to have been reported. There have been inadequate attempts to substantiate claims made in pilot questionnaires.
(3) Torres Pilots has discussed the issue with relevant personnel from both Torres Pilots and Australian Reef Pilots, with such personnel considering that the claims of underreporting are overstated.
(4) Torres Pilots has in place a 'no blame' environment, but does not consider AMSA has adopted such an environment. AMSA issues pilots and pilotage provider with 'please explain' letters and warnings of possible licence suspension or cancellation for any suspected pilot violation of Marine Orders Part 54 or specifically, the FMP. AMSA vigorously enforces pilot and service provider regulatory compliance even when any suspected breach is of a very minor nature.
The safety action proposed by TP has the potential to adequately address the safety issue for the company’s operations.
This response from TP, in most part, repeats its earlier response of 21 Jan 2013 with no relevant addition toward addressing the safety issue.
No evidence has been provided to indicate effective implementation of any safety action to address the safety issue for TP’s operations or suggest progress in addressing the issue.
This response from TP repeats material from its submission to the draft report, rejecting the existence of the safety issue. No relevant information or evidence to support TP's proposed safety action as stated in its response of 21 January 2013 has been provided.
No evidence has been provided to indicate implementation of any safety action proposed by TP on 21 January 2013. Instead, the response rejects the safety issue.
Torres Pilots’ (TP) response repeated its partial rejection of ATSB’s findings on risk event and incident reporting. Torres Pilots also repeated its concerns about AMSA’s approach to this matter (as described in the report and stated in its previous responses).
Torres Pilots advised that it has taken action to address the safety issue and facilitate action taken by AMSA, and submitted relevant documentation as evidence of its actions. Torres Pilots stated that it has developed a risk management framework and the company continues to promote a no-blame environment. TP’s safety management system (SMS), pilots’ code of conduct and pilots’ contract all require the reporting of incidents.
The summary of TP’s non-compliance register (incident reports) lists 33 reports in the 2014 calendar year; an increase from an annual average of six reports over the previous 4 years. Torres Pilots indicated that it investigates reported incidents within the scope of the available information and uses its investigation findings to improve its SMS.
The remaining part of TP’s response described its other safety initiatives, which include:
The safety action taken by TP, together with supporting evidence provided indicates that it has made significant progress in addressing the safety issue for its operations. However, taking into account TP's concerns with respect to AMSA’s approach, ATSB will re-assess the safety issue after TP’s next update.
Torres Pilots’ (TP) provided updates on 27 November 2015 and 25 January 2016. These updates, in part, repeated previous commentary that TP had submitted during the investigation and after the final investigation report was published. The following summarises the main points of the recent updates.
Torres Pilots repeated its partial rejection of ATSB’s findings on risk event and incident reporting, stating that it does not accept that there was a tenfold underreporting of incidents. Torres Pilots also repeated its concerns about AMSA’s approach to incident reporting and related matters, citing a recent example, to support its view. These ongoing TP concerns have been reported in its previous responses as published and detailed in the investigation report. However, TP’s update also stated that since the ATSB investigation ‘AMSA’s governance of coastal pilotage has markedly improved’.
In terms of safety action to address the safety issue, TP advised that it has appointed a dedicated safety management system, risk, and compliance manager. The manager’s duties include a focus on risk event and incident reporting matters. This update also repeated safety action listed in TP’s previous update. Supporting evidence, such as TP’s non-compliance register summary, was not provided on this occasion.
Torres Pilots’ (TP) update indicates that it continues to address risk event and incident reporting through its safety management system (SMS). While TP partially rejects this safety issue and does not accept a tenfold underreporting of incidents at the time of the investigation, it has taken relevant safety action. The summary of TP’s non-conformance register indicates a significant increase (more than five times) in the number of risk events/incidents reported in 2014 than the annual average over the previous 4 years.
Although TP still has concerns with respect to AMSA’s approach to incident reporting, it does acknowledge that AMSA’s governance of pilotage has improved since the investigation.
The continued development and implementation of TP’s SMS in compliance with AMSA’s requirements could adequately address this safety issue for TP’s operations. The updates indicate that the issue has been partially addressed for its operations.
The Australian Maritime Safety Authority (AMSA) advised the ATSB that:
In MO 54 issue 5 reporting has been highlighted. As a result of input from the industry following the implementation of MO 54 issue 5 amendments were made to more clearly identify reporting requirements. In addition, on-line reporting capability has been developed within AMSA (SV-HH I AMSA 355 form).
AMSA recognises that there is an educational and cultural aspect to reporting, and notes similar issues with occupational health and safety reporting.
AMSA reacts to ‘informal’ reports as appropriate given that such reports can include hearsay, anonymous emails and unverified third party information. In response to this safety issue AMSA will be seeking additional opportunities to encourage pilot feedback and reporting, recognising the increasing use of electronic information exchange systems.
Objective evidence available to AMSA, such as records available from REEFVTS does not indicate as high a level of under-reporting as that found in the ATSB survey of pilot opinions.
The ATSB considers the safety action taken and proposed by AMSA has the potential to partly address the safety issue in relation to the under-reporting of risk events. However, the effective implementation of pilotage provider safety management systems along with the development of an appropriate safety culture in coastal pilotage is also crucial to addressing the safety issue.
Objective evidence of incident reporting available to AMSA, including records available from REEFVTS, does not support the findings of the ATSB survey of pilot opinions that ‘there was significant underreporting of incidents by pilots due to factors including personal disadvantage, lack of corrective action taken, no risk reduction and remuneration risk/organisational pressure’.
Notwithstanding this, continuing action by AMSA to manage risk event and incident reporting includes: seeking additional opportunities to encourage pilot feedback and reporting; monitoring reports received to AMSA; and recognising the increasing use of electronic information exchange systems to more easily facilitate reporting.
AMSA reiterates that it reacts to ‘informal’ reports as appropriate given that such reports can include hearsay, anonymous emails and unverified third party information.
AMSA has implemented an internal process to record and analyse reports made by pilots and to deliver the updates on the information assessed to the pilots and providers through the forum of the Combined Pilotage Group meetings.
AMSA will continue to encourage and foster the development of a safety culture in pilotage, including support of the various initiatives to promote a structured approach to anonymous reporting such as the ATSB Repcon marine system and the international CHIRP maritime system (Maritime Confidential Hazardous Incident Reporting Programme).
The safety action taken and ongoing by AMSA should adequately address the safety issue by initiating and supporting effective pilotage provider safety management systems.
AMSA provides incident report updates at each CPG meeting in a common template. In addition, as per discussion at CPG64, AMSA has developed a ‘safety alert’ template which could be used in the future if there is an urgent safety message that needs to be forwarded to the pilotage providers.
As part of a greater awareness of reporting in the maritime environment, VT&PS is working with other areas of AMSA on a coordinated incident reporting and management tool.
The safety action taken and ongoing by AMSA should adequately address the safety issue by initiating and supporting effective pilotage provider safety management systems.
AMSA provided information on the REPCON Marine (Voluntary and Confidential Reporting) Scheme at the recent Combined Pilotage Group (CPG) meeting #66, held in Brisbane on 6 March.
The draft revised Marine Order also seeks to reduce regulatory burden related to incident reporting.
At each CPG meeting (including the most recent held 23 July 2014), AMSA continues to encourage and remind pilotage providers and pilots to report all incidents to AMSA as required.
The ATSB acknowledges the action that AMSA has taken to encourage risk event reporting to address the safety issue. Since two of the pilotage providers have not provided any evidence to indicate how they have addressed the issue, the ATSB would welcome advice from AMSA on progress made by providers based on its audits of their safety management systems.
AMSA invited a representative from the ATSB to provide a presentation regarding the REPCON Marine (Voluntary and Confidential Reporting) Scheme at the recent Combined Pilotage Group (CPG) meeting #66, held in Brisbane on 6 March. Although the ATSB representative could not attend, AMSA provided an overview of the scheme and distributed RECPON information flyers to pilotage stakeholders accordingly.
The draft revised Marine Order also seeks to reduce regulatory burden related to incident reporting.
As part of the review of Marine Order 54, AMSA amended relevant sections in the 2014 version to simplify incident reporting arrangements and encourage increased reporting. Changes included accepting verbal reports to REEFVTS to constitute the provision of an incident report, and removing the requirement for pilotage providers to also report incidents already reported by a respective pilot.
As part of AMSA’s annual compliance audit regime, AMSA has encouraged pilotage providers to mirror the incident reporting requirement detailed in MO54 within the providers’ respective Safety Management System (SMS). These reporting requirements are now clearly defined in each provider’s SMS.
Pilotage-related incident reporting is also addressed as part of the current AMPTC curriculum (as approved by AMSA).
AMSA continues to encourage pilotage providers and pilots to report all incidents as required (such as at each Combined Pilotage Group (CPG) meeting).
AMSA considers that the actions taken to date in response to the ATSB’s original recommendation have adequately addressed this issue.
The ATSB acknowledges the action taken by AMSA to encourage safety action by pilotage providers and recognises AMSA's position that it has adequately addressed the safety issue. However, based on responses submitted by the pilotage providers, and recognising the importance of the issue, the ATSB considers that further and ongoing action is necessary. The ATSB will seek additional evidence from two of the pilotage providers, and welcomes advice from AMSA with regard to progress made in addressing this safety issue.
AMSA’s pilotage provider audit framework for assessing compliance with the requirements prescribed in Marine Order 54 (MO54) includes incident reporting and ensures each provider’s safety management system (SMS) includes specific content related to marine incident reporting procedures. In some instances, these requirements are detailed in a provider’s standard operating procedures (SOP), or code of conduct, which necessarily form part of the respective provider’s SMS. Reference is made to:
- Australian Reef Pilots’ Pilotage Operations SMS, Chapter 4, Section 11;
- Torres Pilots’ SMS, Paragraph 19; Code of Conduct for Pilots; and
- Hydro Marine Pilot’s SOP (Code of Practice), Paragraphs 4 and 5.
The inclusion of such procedures and incident reporting methodologies within pilotage provider’s SMS supports compliance with the incident reporting requirements detailed in MO 54. Further, providers have established arrangements such that compliance with each provider’s SMS is a condition of a pilot’s employment (or contract), hence a direct chain of responsibility has been established between the requirements in MO54, the provider’s SMS and the pilot’s employment. Such an arrangement supports the reporting of MO54-defined coastal pilotage marine incidents to the maximum extent possible noting that in addition to the regulatory requirements in MO54, a deterrent for non-reporting has also been established.
AMSA has also simplified the incident reporting arrangements in 2014 for both individual pilots and pilotage providers via amendments to MO54. These amendments were implemented to:
- Reduce the administrative burden associated with incident reporting on both the individual pilot and the pilotage provider;
- Simplify the reporting process; and
- Encourage the reporting of coastal pilotage related marine incidents as defined in MO54.
A standing agenda item which discusses the importance of incident reporting and provides the opportunity to discuss ‘lessons learned’ from appropriate reported incidents, is included as part of the Combined Pilotage Group (CPG) meetings. CPG meetings are chaired by AMSA and bring together coastal pilotage stakeholders three to four times per year. AMSA intends to retain this standing agenda item to support pilot awareness regarding the requirements for incident reporting. Providers and pilots attending meetings are encouraged to report all incidents and the minutes of meetings are available to all pilots.
An updated Pilot Advisory Notice (PAN) 3/2015 titled Incident Reporting also refers to these obligations and available on AMSA’s internet site.
The ATSB acknowledges the action taken by AMSA to encourage safety action taken by each of the three pilotage providers to address this safety issue through their safety management systems (SMS) in compliance with regulatory requirements. The ATSB considers that, in the current framework where each provider is responsible for managing incident reporting through its SMS, AMSA has implemented adequate regulatory and associated measures aimed at progressively addressing the issue.
Torres Pilots advised the ATSB that it rejects the safety issue. Reasons submitted by Torres Pilots in support of this statement included:
The ATSB has reviewed Torres Pilots’ submission, addressed its comments in detail within the report and does not consider that they address the safety issue.
