Marine safety investigations & reports

Grounding of the passenger vessel True North

Investigation number:
Status: Completed
Investigation completed


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At 2304 on 7 August 2004, the 34.56 m passenger vessel True North, with 38 people on board, ran aground in the entrance passage to St. George Basin in Western Australia's Kimberley region. At the time of the grounding, the master was alone on the bridge. The vessel was in automatic navigation mode with course adjustments initiated by means of a GPS navigation system linked to an Electronic Chart System (ECS), that transmitted course adjustment information to an autopilot. No pollution resulted from the grounding, although several passengers received minor injuries during the initial impact.

True North had draughts of 1.5 m and 2.2 m forward and aft respectively and remained aground for about one hour. It floated clear of the rock on which it had grounded on the incoming tide and moved under its own power to an anchorage south of one of the islands in St. George Basin. The vessel was beached by the master on the morning of 8 August and a full appraisal of the damage made.

On 9 August, a repair team and equipment was flown to the vessel by float plane from Broome, Western Australia. The passengers and non-essential crew were then flown to Broome and repair work commenced. Temporary repairs were carried out while the vessel was beached in between the periods of high water. These repairs were completed by 11 August and True North departed St. George Basin for Darwin, where permanent repairs were to be effected.

The vessel arrived at repair facilities in Darwin on 14 August. True North was able to depart Darwin for Wyndham on 26 August to resume its cruise schedule.

The report concludes that:

  • True North grounded on or near Strong Tide Point in unsurveyed waters while being navigated by an auto helm unit and ECS receiving position information from GPS satellites.
  • GPS derived positions plotted on the ECS differed from the vessel's true position, possibly caused by:
    • GPS system inaccuracy;
    • Geodetic datum ambiguity;
    • The ECS operating on a common user personal computer which allowed possible corruption of the ECS operating system;
    • A change in the GPS receiver parameters;
    • Loose wiring or connections in the on board systems; or
    • A combination of the above.
  • Too much reliance was placed on the accuracy of GPS positions and the GPS positions plotted on the vessel's ECS were not adequately checked by other navigational means.
  • A proper lookout was not maintained by visual, radar and other means to ensure the vessel remained in safe water.
  • At the time of the grounding, it is probable that the master was suffering from some effects of fatigue as a result of his work routine.
  • There were deficiencies in the procedures which dealt with the mustering of passengers in that:
    • The initial safety briefing was not sufficiently comprehensive;
    • company orders in respect of lifejackets and emergency signals were not followed; and
    • company practices in the provision of emergency information and procedures did not meet WA legislative requirements.

The report recommends that:

  • Owners and operators of vessels running Electronic Chart Systems should do so on dedicated computers.
  • Owners, operators and masters of vessels regularly operating in confined waters should revise procedures governing the use of GPS and auto pilot systems.
  • Owners and operators of passenger vessels should ensure information concerning muster areas, emergency signals and instructions and diagrams of how to don lifejackets, are included in any passenger information kits in cabins, and on the inside of all cabin doors, in order to comply with state/territory regulations.
  • True North Cruises should review the procedures associated with passenger briefings and the emergency information displayed in the passenger cabins and vessel common rooms.
  • Owners, operators and masters of non-SOLAS vessels should consider the introduction of effective fatigue management policies and practices on board vessels.
  • AMSA and state/territory marine authorities should carefully consider the type of operation and area of operation when determining the safety manning of vessels of any length.
  • Western Australia's Department of Planning and Infrastructure should consider recommending the amendment of WA marine legislation to allow for the option to review and, if necessary, change the safety manning requirements for state registered vessel.

Related Documents: | Media Release |

Download Final Report
[Download  PDF: 1.73MB]
General details
Date: 07 August 2004   Investigation status: Completed  
Time: 2304    
Location: St. George Basin    
State: Western Australia    
Release date: 03 May 2005   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Vessel details

Vessel details
Vessel Passenger (USL Class 1B ship)  
Flag Aus  
IMO 9192105  
Type of operation Passenger  
Damage to vessel Minor  
Departure point St George Basin WA  
Departure time 2304  
Destination Darwin  
Last update 19 May 2016