The National Transportation Safety Board (NTSB) determined that a tug identification error by a pilot led to the crude oil tanker Platanos striking a pier while undocking at the Martinez Refining Company Wharf near Martinez, Calif., in October 2024.
In a recently released report, the NTSB noted the contact occurred around 4:00 am local time on October 14, 2024, as the 818’ tanker was departing the refinery berth in ballast for an anchorage near the San Francisco Oakland Bay Bridge. The vessel’s port quarter struck a concrete dolphin and fender support panel. No injuries or pollution were reported. Total damage to the vessel and pier was estimated at about $500,000.
According to the report, a San Francisco Bar pilot boarded the vessel shortly before departure and conducted a master-pilot exchange outlining the undocking plan. Two tractor tugs were assigned to assist with the maneuver, one secured forward and one aft on the starboard side. The plan called for both tugs to pull the vessel off the pier, with the aft tug pulling faster than the forward tug to keep the stern clear of the pier in a 1.9-knot ebb current.
After mooring lines were released, the pilot ordered the forward tug to pull away at increasing power while the aft tug pulled at minimum power. Shortly afterward, the pilot ordered the aft tug to stop and instructed the other tug to adjust its position relative to the ship. During the maneuver, the vessel’s stern moved toward the pier, and despite corrective orders, the ship’s port quarter contacted the pier.
The contact resulted in a penetration above the waterline into a pump room void space and additional hull plating damage, but no flooding occurred. The pier sustained structural damage to the dolphin and fender system.
Investigators found there were no mechanical or equipment failures on the tanker or the assisting tugs, and weather and visibility conditions were favorable. The primary factor was the pilot transposing the names and positions of the two tugs on his reference card before the maneuver began. Because of this error, orders intended for the aft tug were given to the forward tug and vice versa. The result was the bow being pulled away from the pier faster than intended, allowing the stern to drift toward the pier under the influence of the ebb current, contrary to the pilot’s plan.
The pilot later told investigators he believed he may have mixed up the tug assignments and noted the mistake after the vessel cleared the pier.
The NTSB said the pilot may have been affected by fatigue or distraction when writing down the tug positions. The pilot reported getting about 4.5 hours of sleep before the early-morning operation, and the contact occurred during a circadian low period between 3:00 am and 5:00 am.
The NTSB also noted that bridge resource management principles require bridge teams to identify and correct errors before they lead to incidents. Although the vessel’s master warned the pilot that the stern was too close to the pier shortly before the contact, the incorrect tug orders had already placed the vessel in a position where the contact could not be avoided in time.
The NTSB concluded the contact was caused by the pilot transposing the tug positions on his reference card, resulting in incorrect tug orders during the undocking maneuver. Contributing factors included the strong ebb current and possible fatigue or distraction affecting the pilot’s attention during the maneuver planning process.
