The ATSB's report into the collision between the Australian fishing vessel Apollo S and the Liberian registered bulk carrier Grand Rodosi contains important messages for pilots and ships' crews.
The collision occurred at Port Lincoln, SA, on 8 October 2010 while Grand Rodosi was berthing. As a result of the collision, Apollo S was crushed against a wharf and sank. Grand Rodosi sustained small holes in its bow shell plating.
The investigation found that despite the pilot ordering astern movements, the ship's main engine did not respond. The chief engineer, who was operating the main engine start/fuel lever in the engine room control room, did not allow sufficient time for starting air to stop the ahead running engine. Consequently, when fuel was introduced into the engine, it continued to run ahead, despite the astern telegraph orders.
The investigation also found that the chief engineer's mistake was not noticed on the ship's bridge or in the engine control room until after the collision; that the master/pilot information exchange was less than optimal; and that bridge resource management could have been better during the passage to the berth.
Following the incident, Newlead Bulkers, the ship's managers, amended their on board procedures to ensure crew monitor the direction of main engine turning after each engine order. They have also increased awareness through their fleet about this type of incident occurring.
Flinders Ports, the provider of pilotage services in Port Lincoln, has revised their risk assessment for the manoeuvre undertaken during Grand Rodosi's berthing to include new preventative, as well as restorative, measures to be followed. Flinders Ports has also revised their pilotage passage plan to include indicative courses to be followed and speed zones. It is of paramount importance that pilots and crews remain aware of main engine movements and check engine tachometers following every movement to ensure that the engine is operating in the desired direction. This is particularly important when main engines are being operated in manual control.
In addition, pilots and the bridge teams should ensure that all necessary information is exchanged at the beginning of a pilotage, including courses to be followed and speeds at critical positions during the passage, so that all involved in the pilotage have a shared mental model and a good understanding of the pilotage before it begins.
Last update 04 January 2013