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Marine Safety Investigation Report - Final

The Malaysian flag container ship Bunga Teratai Satu sailed from Singapore on 26 October 2000, bound for Sydney via the inner route of the Great Barrier Reef with a cargo of 857 containers. A licensed pilot was embarked to conduct the navigation through the inner route between Goods Island and Cairns.

At 0554 AEST on 2 November 2000, Bunga Teratai Satu disembarked the pilot at Yorkeys Knob, off Cairns, at the southern limit of the compulsory pilotage area.

At 0600, 'full away' was rung and the vessel resumed its passage to Sydney on a course of 120° (true). A programmed way-point, at position 16° 52.8' S, 146° 02.3' E, was reached at 0700. At this way-point, the course was supposed to be altered to 164° (true) to round Fitzroy Island and take the vessel to the west of Sudbury Reef. However, no course alteration was made.

The ship was reporting under the Great Barrier Reef Ship Reporting System, REEFREP, administered from Reefcentre, Hay Point. This system requires ships transiting the inner route to report at certain positions within the inner route. To help enforce compliance with pilotage and reporting requirements the normal entry points to the inner route are monitored by radar. In the limited areas covered by radar, the system fulfils a secondary, monitoring role, to improve safe navigation.

Bunga Teratai Satu had been acquired as a target at Reefcentre when it entered the area covered by the Green Island radar system at about 0430. From about 0715 to 0725, the Reefcentre operator was attempting to re-establish lost targets on the Hammond Island radar display covering the western area of Torres Strait. Just before 0716 Bunga Teratai Satu entered the restricted zone (2 miles off Sudbury Reef) but the Reefcentre operator did not notice the alarm message as he worked on other tasks.

At about 0723, the ship struck the north end of Sudbury Reef at a speed of over 20 knots on a heading of 120°. It was about 1 3/4 hours after low water and the vessel's bow rode some 100 metres onto the reef leaving the stern in approximately 12 metres of water.

Nobody was hurt as a result of the grounding and no oil or other pollutant escaped from the ship. The grounding resulted in mechanical damage to the reef and the yet-to-be assessed effects of the ship's anti-fouling paint.

The Australian authorities issued detention orders while the ship's situation was being assessed. Bunga Teratai Satu remained fast on the reef until it was eventually refloated with the aid of tugs at about 0930 on 14 November 2000.

The investigation found that the significant unsafe act that resulted in the grounding was the inattention of the mate on watch aboard Bunga Teratai Satu, who was distracted by his wife's telephone call to their family overseas.

However, a number of other contributing factors led to a breakdown in the defences and protections that may have prevented the ship from grounding.

Conclusions

These conclusions identify the different factors contributing to the grounding of Bunga Teratai Satu and should not be read as apportioning blame or liability to any particular individual or organisation.

1. The significant unsafe act that resulted in the grounding was that the mate allowed himself to become distracted, for a period of about 15 minutes, from the navigation of the ship by a telephone conversation between his wife, who was on the ship's bridge wing, and his family overseas.

2. From about 0645 to 0715 the mate had become preoccupied with arranging and making private telephone calls while the ship was in cellular phone range of the coast, rather than monitoring the ship's course, speed, position and his other watchkeeping duties.

3. The manner in which the mate maintained his watch on 2 November 2000 lacked appropriate motivation and fell well below proper professional standards.

Based on the evidence available, the following underlying, or 'latent', factors are considered to also have contributed or are relevant to the incident:

4. The ship's GPS cross-track error alarm was neither loud enough nor strident enough to attract urgent attention.

5. The absence of an appropriate level of Bridge Resource Management on the vessel allowed a basic error by oneperson to result in a serious accident.

6. The Reefcentre operator was aware that Bunga Teratai Satu was in the area of the Green Island radar coverage, but the loss of radar signal of vessels in Torres Strait caused him to focus solely on the Hammond Island display and to concentrate on re-entering the information into the Traffic Information Module.

7. The frequency of annunciation of Traffic Information Module alarms and associated radar alarm systems had led to the desensitising of Reefcentre operators to the whole TIM alerting system.

8. However, given the setting of the restricted area off Sudbury Reef at two miles and the speed and circumstances prevailing on the bridge of Bunga Teratai Satu, it is unlikely that any advice provided by the Reefcentre operator under the Reefcentre procedures would have prevented the grounding.

In relation to the perception that the radar system was not reliable:

9. The radar units operated consistently within the design availability criteria.

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