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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