A Maryland state pilot guiding the 1,095’ container ship Ever Forward was distracted by his cell phone use before the vessel ran aground March 13 in Chesapeake Bay, according to a new Coast Guard report on the incident.
The Hong Kong-flagged Evergreen Marine Corporation vessel was heading south from the Port of Baltimore to Norfolk, Va., with 4,964 containers on board, when it grounded outside the Craighill Channel near lighted buoy 16 around 8:20 p.m. according to the narrative in the Coast Guard report.
While critical of the pilot’s cell phone distraction, Coast Guard investigators also reported that the Ever Forward’s third mate and bridge team should have been more assertive when they began to suspect a critical waypoint was missed going into a turn.
Investigators summarized “the incident’s causal factors to be the pilot’s failure to maintain situational awareness and attention while navigating, and inadequate bridge resource management.”
The grounding led to an extended drama with the ship stranded for more than a month, as a unified command of the Coast Guard, Maryland Department of the Environment, and Evergreen organized a massive salvage plan to free the ship. Dredging, cargo lightering and complex towing plans all had to be used before the Ever Forward was freed April 17.
The Coast Guard report’s first recommendation calls for “vessel owners and marine operators develop and implement effective policies outlining when the use of cell phones and other portable electronic devices is appropriate or prohibited.”
Secondly, vessel owners and operators must “ensure and promote crew awareness of policies regarding the duties and obligations of officers on watch for the safety of the ship, even when a pilot is embarked,” the report says.
The grounding happened little more than two hours after the Ever Forward had departed the Seagirt Marine Terminal in Baltimore. The report notes the departure was “slightly delayed due to a line handling issue at the facility.”
At around 8:17 p.m., with the pilot and a team of third officer, deck cadet and able bodied seaman on the bridge, “the vessel passed its charted waypoint, marking a turn to approximately 180 degrees True that needed to be executed in accordance with the voyage plan. No order was given to turn the vessel and the helmsman maintained the previously ordered course of 161 degrees True,” according to the report narrative.
At 8:18 p.m, the pilot – referred to as Pilot 1 in the Coast Guard narrative – “recognized the vessel was past its turn and ordered 15 degrees rudder to starboard. The vessel grounded outside the Craighill Channel, east of Lighted Buoy 16. Pilot 1 immediately attempted to use astern propulsion to free the vessel.”
During the transit from Baltimore the pilot was relying on his portable pilot unit to navigate, and just prior to the grounding he exited the active navigation of his PPU to view a previous transit, according to the report. The pilot had also made a series of five phone calls totaling over 60 minutes during the 126-minute transit, sent two text messages “and began drafting an email immediately before the grounding occurred regarding issues he experienced with facility line handlers,” the report says, citing a review of ATT cell phone records.
The Ever Forward’s bridge crew told Coast Guard investigators that the pilot “was frequently on his cell phone and appeared agitated.”
“Immediately prior to the grounding, the Third Officer, a Chinese national, believed that the vessel had missed the waypoint to turn. However, instead of directly telling Pilot 1 that the turn had been missed, he repeated the heading multiple times in an attempt to cue Pilot 1 of the vessel’s situation,” the report says.
The third officer “acknowledged that as the expert on local waters, he was hesitant to question Pilot 1’s expertise and familiarity of the channel,” the investigators noted. “This may have in part been due to the Third Officer fearing he may offend Pilot 1 or cultural differences regarding seniority.”
But if the third officer and bridge crew had been more assertive, and called the ship’s master to the bridge, the outcome could have been different, the report says.
The Maryland Board of Pilots suspended the pilot’s license Oct. 21 with a finding “that the public health, safety, and welfare imperatively required this emergency action.” The pilot has requested a hearing, the report notes.
The pilot told investigators he solely relied on his PPU to navigate and did not use any ship’s equipment or charts. As the Ever Forward was approaching the critical turn, the pilot was “taking a screenshot on his PPU of a previous trip to text another member of the Maryland Pilots Association in regard to an ongoing issue with line handlers,” the report says. He then “began to draft an email on his cell phone in order to follow-up with a text message.”
The PPU “automatically records all active vessel movements unless a replay of a previous trip is begun in the middle of an active trip. The PPU will then stop recording the active trip and save the active vessel movement up until the point the PPU user navigated away from the active trip to view a previous one,” the report says. “It will then save that active trip into a file and start a new, separate file once the user returns to the active trip screen.
“This means that there will be a data gap in the active trip for the duration of time that a user views a previously recorded trip. In this incident, Pilot 1’s PPU had two saved files with a gap in recording from 2015 to 2019, approximately the time that Pilot 1 stated he was viewing a previous recording to retrieve information to identify the line handler issue.
"Since Pilot 1 stated that he used no navigational equipment aside from his personal PPU, and the PPU recording was gapped from 2015 to 2019, the evidence shows that for this duration of time, Pilot 1 was not actively engaged in navigating the vessel immediately prior to the grounding.”
In summary the Coast Guard report says the pilot “potentially missed cues from the bridge team when they repeated the vessel’s heading as the turn was approaching, and again after the turn had been missed.”
Relying on his PPU, the pilot “was unable to accurately determine the vessel’s location in real time. Had Pilot 1 refrained from drafting email correspondence and placing and receiving personal or non-urgent professional calls, it is possible he would have maintained better situational awareness and properly executed the turn in a timely manner, avoiding the vessel grounding.”
Addressing the Ever Forward bridge crew’s responsibility, the report says the ship’s safety management system “dictates that if the vessel experiences difficulty maintaining course or any doubts arise in regard to the vessel’s situation, the officer on watch shall call the Master.
"After the Third Officer’s attempts to cue Pilot 1, he did not immediately notify the Master. Had the Third Officer immediately notified the Master, the likelihood of an alternate outcome is low due to the short amount of time between the point when the turn south was missed and the grounding.”