Stage

• On Scene
• Factual Collection
• Analysis
• Final Draft
• Closure

On October 14^th, 2024, at 1407 hours local time, while the ship was berthing at Berth West No.20 of Keelung Port, one of the quay gantry cranes on the wharf was struck and toppled by the gantry crane carried on the ship. Damage occurred to both the shore-based crane and the gantry crane on the ship. No injuries or oil pollution resulted from this occurrence.

Conclusions

Findings Related to Probable Causes
• 1. The pilot did not reduce speed or adjust the heading in the outer channel or turning basin before entering the fairway, proceeding directly into the berth approach. Relying solely on visual lookout was insufficient to determine the ship’s position and lateral deviation. The pilot and the ship’s bridge team did not use navigational instruments to monitor the ship’s position and lateral movement, which prevented timely correction of berthing speed and angle. Due to restricted maneuvering space, a gantry crane, carried as a cargo on the ship, made contact with a shore-based gantry crane, causing the latter to collapse and be declared a total loss.
  2. Although the pilot was aware of the berth and fairway conditions prior to pilotage, he did not adequately assess the berthing risks or propose a plan modification or refusal. Insufficient situational awareness during pilotage led to an inadequate evaluation and management of the risks associated with berthing in a confined fairway.
  3. The master of the ship did not fully comply with port entry and departure safety procedures or effectively apply Bridge Resource Management (BRM). The Master–Pilot Exchange (MPX) was inadequate, failing to address critical risk factors such as the ship’s oversized cargo, berth environment, and special handling requirements.

Findings Related to Risk
• 1. The pilot executed the maneuver without a comprehensive berthing plan and failed to recognize that the actual maneuvering width of the fairway was limited to 81 meters, significantly increasing the risk during berthing.
  2. The ship management company did not obtain specific berthing information for Keelung Port, resulting in a risk assessment that omitted port-area operations. Additionally, the Master failed to conduct the required company risk assessment before entering the port and did not consider the clearance distances between the shipborne crane and shore facilities.
  3. Berth management controls at Keelung Port were ineffective. For ships carrying oversized cargo, no special application or review procedures were established. The failure to clear West No. 23 Berth as originally planned further restricted maneuvering space and increased operational risks.
  4. The Keelung Port Vessel Traffic Service (VTS) Guidelines apply only to “special ships” and lack an application and review mechanism for vessels carrying oversized cargo, missing the opportunity to prevent incidents.
  5. The ship’s agents and China Container Terminal Corporation had completed the pre-arrival declaration and coordination for the ship’s port call; however, their discussions focused solely on cargo discharge arrangements and neglected the risk assessment related to the ship’s oversized load.

Other Findings
• 1. The ship held valid statutory certificates issued by the China Maritime Safety Administration and a valid Safety Management Certificate issued by the China Classification Society. All certificates and procedures were current, with no abnormal remarks.
  2. The ship had no bow thruster; its drafts upon arrival were 4.8 m forward and 5.2 m aft. The ship’s main engine, auxiliary machinery, and steering gear functioned normally, ruling out equipment failure or structural damage as causal factors.
  3. At the time of the occurrence, the weather was clear with a rising tide, east-southeast winds at Beaufort scale 4, and good visibility, ruling out environmental causes.
  4. Both pilots held valid pilot licenses issued by the Ministry of Transportation and Communications of the Republic of China (R.O.C.).
  5. The Master and 16 crew members held valid Certificates of Competency issued by the China Maritime Safety Administration.
  6. The two pilots, two tug masters, and the ship’s crew maintained normal work and rest hours during the 72 hours preceding the occurrence, thereby ruling out fatigue.
  7. One of the pilots had previously, about 7 to 8 years earlier, handled the pilotage of a vessel carrying wind-turbine components and had served as a co-pilot assisting from ashore.
  8. Keelung Port has experienced six recent incidents involving ships that made contact with wharves or gantry cranes, or ran aground.