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At about 2330 on 20 April 2001, a licensed pilot boarded the Russian flag container ship Maksim Mikhaylov in the port of Brisbane. The pilot exchanged the necessary pilotage information with the master. He then set up his electronic charting system (ECS) and differential global positioning system (DGPS) display on a bridge front window sill to the port side of the centre line in the wheelhouse. The vessel sailed from Fisherman Islands container berth at 0015 on 21 April.

The vessel cleared the berth without incident. The pilot noticed at this stage that, as the tugs took minimum weight on their lines, the vessel heeled 3 or 4 indicating that the ship had reduced residual stability, that is the ship appeared to be tender. Once established in the Bar Cutting, the pilot requested that the ship's speed should be increased to full sea speed for the outward passage via East Channel. At about this time, the second mate took over as officer of the watch and a new helmsman took over the steering. The master remained on the bridge, mostly on the starboard bridge wing. The night was fine and clear with excellent visibility, there was little wind and a calm sea. The tide was on the last of the ebb.

Clear of the Bar Cutting, the pilot ordered an alteration of course to 060 true. Ahead, the beacons marking East Channel could clearly be seen. The pilot alternated between the radar and his ECS display. The second mate fixed the ships position at five minute intervals and the master remained on the starboard bridge wing. The helmsman steered a straight course and demonstrated that he understood helm orders.

At about 0114, the pilot ordered five degrees of port rudder to enter the East Channel. The ships swing started to accelerate and the rudder was ordered to amidships. Maksim Mikhaylov contacted Beacon E5 at about 0115:30.

Other than superficial paint damage Maksim Mikhaylov sustained no damage, but the beacon suffered substantial damage. The pilot reported the incident at 0125.

The ship continued on passage, anchoring off Point Cartwright where the master and pilot provided a statement to an official of Queensland Transport and a preliminary assessment of any damage to the ship was made.

Conclusions

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

  1. After the initial turn was established, the turn to port was maintained by mistaken application of port rudder as a result of either the pilot giving the wrong order, or the helmsman applying the wheel to port rather than starboard. The rate of turn was exacerbated by the ship's low level of reserve stability.
  2. The lack of proper monitoring of either the pilot or the helmsman by the master and officer of the watch contributed to the contact with beacon E5.
  3. The lack of proper monitoring of the helmsman by the pilot, whilst he was giving commands and they were being executed, contributed to the contact with beacon E5.
  4. There was a demonstrated lack of Bridge Resource Management.
    - There was a lack of communication between the master and pilot. There was also a lack of oversight of the pilot by the master during the passage.
    - There was no 'shared mental model' with defined limits which could be challenged if exceeded. The ship followed closely neither the pilot's nor the ship's planned route. The ship was on the 'wrong' side of the pilot's proposed route and this was not challenged by the Officer of the Watch.
  5. The pilot was affected by a measurable degree of fatigue. The volume of shipping at that time put an extra demand on pilotage services, resulting in shorter than normal breaks between duty periods. The pilot was at the end of his rostered-on period.

Although not contributing factors it is also considered that:

  • The pilot gave the order to turn from the heading of about 060 to enter East Channel at the position he originally planned. The order was given neither too early nor too late.
  • Language and a proper understanding of the orders given by the pilot were not causative issues in the contact with beacon E5.
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General details
Date: 21 April 2001 Investigation status: Completed 
 Investigation type: Occurrence Investigation 
Location:Moreton Bay  
State: Queensland  
Release date: 19 July 2002 Occurrence category: Incident 
Report status: Final Highest injury level: None 
 
Vessel details
Vessel: Maksim Mikhaylov 
Flag: Rus 
IMO: 7614379 
Type of Operation: Cellular Container 
Damage to Vessel: Minor 
Departure point:Fisherman Islands, Brisbane
Destination:Manila, Philippines
 
 
 
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Last update 19 May 2016