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On the morning of 2 June 1994, the Australian Maritime Safety Authority navigational aids service vessel, Cape Grafton was anchored off Dent Island in the Whitsunday Group, Queensland. Cape Grafton, a diesel/electric powered vessel, had arrived in Australia in March, having been built and fitted out in Spain. The vessel was on its first operational deployment and was scheduled to carry out routine maintenance on Dent Island lighthouse.

At about 0740, Cape Grafton started to weigh anchor to move closer to the lighthouse and to make a lee for the work boat, which was used to convey men and materials to the land.

Anchor was weighed at 0752 and the Master manoeuvred towards the lighthouse turning to starboard, away from the island, before making the necessary lee. At about 0755 the vessel suffered a total loss of power for a few seconds, this 'blacked out' all means of propulsion and instrumentation for a critical period. Although electrical generating power was restored within a few seconds and machinery was restarted, control was not restored in time to prevent the vessel running aground, despite letting go the anchors.

The grounding was relatively minor in nature and Cape Grafton refloated without assistance on the afternoon tide. Nobody was injured and no pollution resulted from the grounding.

Such vessels are required to routinely operate close to the shore or navigational hazards, where commercial vessels would not normally navigate.

While the investigation established operational factors which contributed to this particular incident, significant defects in the ship's systems meant that the vessel was vulnerable to loss of control. Put simply, if the accident had not occurred on 2 June, there is a strong probability that it would have occurred at some time in the future due to incorrect control settings, the configuration of interfaces between the main units in the vessel's propulsion system and deficiencies in the supply of emergency power to essential navigational instruments, as they existed at the time.

The report outlines the background to the incident and considers the contributory factors.

Conclusions

These conclusions identify the different factors contributing to the circumstances and causes of the incident and should not be read as apportioning blame or liability to any particular organisation or individual.

The Inspector concludes:

1. The grounding of Cape Grafton was the chance coming together of a number of factors at a time when the vessel was close to shore in a vulnerable position and reaction time was limited.

2. There is little doubt that, had those on the bridge and in the engine room worked together properly, had the Master thoroughly understood the operation of the propulsion system and the steering, had the secondary systems and local controls available in an emergency been appreciated and had these been utilised, the grounding could have been prevented. This lack of operational knowledge, however, was compounded by significant systems defects and management deficiencies.

3. The investigation found a general lack of understanding, throughout the AMSA Ship Operations staff, of the operation of the ship's systems, control equipment and protective devices, in particular the interfaces between the various units comprising the propulsion system and its controls, the overload protection system, the engine room data-logger and printout, and the emergency generator and switchboard. This was due, in part, to the absence of any instructions or manuals explaining how the different components worked as a system or detailing the interconnections between each unit, the bridge and engine room control centres. This general lack of understanding, and the lack of any drawings of the overall propulsion machinery system, led to the commissioning of the Novamarine report on the functioning of these systems.

4. Both the absence of accurate 'as fitted' drawings and those defects that were factors in the grounding, together with problems experienced in wiring circuits and other systems not directly related to this report, call into question the quality control regimen followed by the various parties involved and the validity of quality assurance in the face of such defects.

It is further concluded that the following factors contributed directly to the grounding of the Cape Grafton:

1. The Master's lack of understanding of the propulsion system and the fact that he:

(a) did not take early action to stop the propulsion motors, or

(b) declutch the propeller shaft, or

(c) utilise the backup pitch and emergency steering controls.

2. The auto slow down system, intended to protect the generators on overload was defective:

(a) it was disconnected at the propeller pitch control central unit;

(b) there had been a failure to ensure that the system was reconnected after defective sensors had been replaced in Brisbane;

(c) it is possible that, even had these wires remained connected, the system would have failed as the overload trips were set too low and the time setting between the overload signal from the generators and the tripping of the generator circuit breaker was incorrectly set.

3. There was a loss of emergency electrical power to the navigational instruments, particularly the rudder angle and pitch indicators, through:

(a) the design of the emergency generator auto-start system, in that it was able to sense that a main generator was running, although the tie breaker between the main and emergency switchboards was open;

(b) the division of the emergency switchboard into essential and non-essential supplies and the supply of power to the bridge instrumentation, pitch control and one steering system, from the non-essential bus.

4. The wiring of the zero pitch interlock between the KaMeWa system and the propulsion motor starters was not properly connected and allowed the propulsion motors to be started with pitch on the propeller.

5. The lack of interlocks requiring the clutches to be disengaged before a propulsion motor could be started.

6. Defects in the management system leading to:

a) the installation of equipment that was not thoroughly tested in all respects;

b) the installation of systems not thoroughly understood by management or ship staff;

c) ineffective quality control during the installation of electrical and control systems;

d) the failure to undertake a suitable risk assessment for the new vessel, relating to its frequent operation close inshore in hazardous waters.

7. The failure of the ship's emergency generator and associated electrical circuits, to comply with Marine Orders Part 20.6.5.1 (d) (ii), in respect of the maintenance of a power supply to the shipborne navigational equipment, which includes indicators for rudder angle, pitch and the operational mode of the propeller.

8. The lack of clear, uniform operational instructions and procedures, common to bridge and engine room, for starting and operating the ship's propulsion and associated machinery.

9. The absence of any contingency planning for the passing of machinery control from the bridge to the engine room under emergency conditions or plans to utilise the backup pitch control and the emergency steering in the steering flat.

10. The absence of any structured training for the operation of Cape Grafton that would have provided an overall concept of the elements of the propulsion system and how they interfaced with each other.

Download Final Report
[ Download PDF: 10.97MB]
 
 
 
 
General details
Date: 02 June 1994 Investigation status: Completed 
 Investigation type: Occurrence Investigation 
Location:Great Barrier Reef  
State: Queensland  
Release date: 23 August 1995 Occurrence category: Incident 
Report status: Final Highest injury level: None 
 
Vessel details
Vessel: Cape Grafton 
Type of Operation: Service vessel 
Damage to Vessel: Minor 
Departure point:Spain
Destination:Australia
 
 
 
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Last update 18 May 2016