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On the evening of 18 June 1998, the Panamanian flag container ship MSC Katie embarked a Port Phillip Sea Pilot off Port Phillip Heads to proceed to Swanson Dock, Melbourne. The vessel crossed Port Phillip Bay at full sea speed and reduced to slow speed for passage up the Yarra River. Three tugs were made fast when the vessel was in the vicinity of the Westgate bridge and the vessel arrived at the swinging basin, off the entrance to Swanson Dock at 2338.

The tugs swung the vessel to starboard so that it was positioned to enter Swanson Dock stern first and the Pilot manoeuvred the vessel slowly up the dock towards the allocated berth, No. 3 East. No vessels were berthed at Nos. 1 and 2 East. As the vessel's bridge cleared No. 2 berth, the aft tug eased the stern in, to angle the vessel towards the berth.

The Pilot ordered dead slow ahead, to bring the vessel to a stop, but the engine failed to start. The starboard anchor was let go and the tugs took the weight to stop the vessel and to pull it away from the berth, but the port quarter of MSC Katie made contact with the stem of P&O Nedlloyd Sydney, berthed at No. 4 East. Both vessels sustained relatively minor damage.

After MSC Katie was safely moored alongside, the reason for the engine failure was traced to a blocked pipe to the main bearing lubricating oil pressure gauge/safety switch. This had created a spurious lubricating oil low pressure reading, which had initiated an emergency trip of the main engine, causing the fuel pumps to lift and preventing the supply of fuel to the engine.


These conclusions identify the various factors that contributed to the incident and should not be read as apportioning blame or liability to any particular organisation or individual.

  • The engine failure was caused by a blockage in the lubricating oil piping to a pressure safety switch. The blockage caused a 'low pressure' alarm, which initiated a main engine emergency trip mode, which in turn prevented the engine being started. There are no engine manufacturer's instructions or recommendations on periodic checking of such piping and it is not standard practice on board ships for such checking to be carried out.
  • The lack of communications, between the bridge and engine room teams, resulted in the bridge team not keeping the engine room team informed of progress; and the engine room team not immediately informing the bridge team about possible ramifications of the engine 'emergency trip' alarm.
  • The lack of Bridge Resource Management principles on board, resulted in the members of the ship's bridge team not informing the Pilot about the main engine emergency trip and not keeping the Pilot informed about engine response.
  • There was an absence of a safety assessment of, and contingency planning for, the berthing operation. In addition there was an absence of sufficiently detailed discussion of the berthing operation under Bridge Resource Management principles. As a result, no suitable lines were ashore to check the movement astern and, during the final approach to the berth, the bow tug was not in the optimum position to stop the vessel's movement astern, thus there were no safety barriers in place.
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General details
Date: 18 June 1998 Investigation status: Completed 
Location:Melbourne Investigation type: Occurrence Investigation 
State: Victoria  
Release date: 22 December 1998  
Report status: Final Occurrence category: Incident 
 Highest injury level: None 
Vessel details
Vessel: MSC Katie 
Flag: Pan 
IMO: 7434444 
Type of Operation: Container ship 
Damage to Vessel: Nil 
Destination:Swanson Dock, Melbourne
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Last update 19 May 2016