Marine safety investigations & reports

Independent investigation into the grounding of the Hong Kong registered products tanker Atlantic Blue at Kirkcaldie Reef in the Torres Strait on 7 February 2009

Investigation number:
262-MO-2009-001
Status: Completed
Investigation completed

Summary

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At 2200 on 6 February 2009, a coastal pilot boarded the products tanker Atlantic Blue for its intended eastbound transit of the Torres Strait. The ship was nearly fully laden with a cargo of unleaded petrol and was bound for Townsville, Queensland.

The passage progressed normally and at 0130 on 7 February, Atlantic Blue's heading was altered to 066º (T). However, no allowance was made for the 25 knot north-westerly wind abaft the port beam and the east-going tidal stream. Consequently, the ship made good a course of 070º (T) and by 0235, it was 1 mile south of the planned track.

At 0237, 0246 and 0256, the pilot made heading adjustments until the ship's heading was 059º (T). These small adjustments did not bring Atlantic Blue back on track as it progressed towards Kirkcaldie Reef. After 0307, as the ship closed on a shoal about 1 mile ahead, the pilot began altering the heading further to port. This course alteration was too little, too late and at 0312, Atlantic Blue's bow grounded on a sandy shoal. The hull remained intact and there was no pollution. At 0700, the ship refloated on the flooding tide and was manoeuvred clear of the reef.

The investigation found that the ship grounded because its progress and position were not effectively monitored by the bridge team and inadequate action was taken to bring it back on track. Bridge resources were not managed effectively, off-track limits were not defined and the bridge team did not have a shared mental model of the passage. The report identifies safety issues in relation to the ship's passage planning procedures; the coastal pilotage check pilot regime and the coastal vessel traffic service's monitoring system. Safety actions to address all the issues have been taken or proposed by the relevant parties.

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Alternate: [Download  DOC: 5.6MB]
 

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Safety Issues

Go to MO-2009-001-SI-01 - Go to MO-2009-001-SI-02 - Go to MO-2009-001-SI-03 - Go to MO-2009-001-SI-04 -

Ship's passage planning procedures

Atlantic Blue’s safety management system procedures did not require specific off-track limits to be included in the passage plan or otherwise ensure that limits for effective track monitoring were always defined.

Safety issue details
Issue number: MO-2009-001-SI-01
Who it affects: All ship owners, operators, managers, masters and deck officers
Status: Adequately addressed

Pilotage SMS and check pilot regime

The pilotage system used by Atlantic Blue’s pilot did not define off-track limits or make effective use of recognised bridge resource management tools in accordance with the Queensland Coastal Pilotage Safety Management Code and regular assessments of his procedures and practices under the code’s check pilot regime conducted over a number of years had not resolved these inconsistencies.

Safety issue details
Issue number: MO-2009-001-SI-02
Who it affects: All pilotage organisations
Status: Partially addressed

Shore monitoring of shallow water areas

The ‘shallow water alert’ generated by the Great Barrier Reef and Torres Strait Vessel Traffic Service’s (REEFVTS) monitoring system did not provide adequate warning of Atlantic Blue entering shallow water because the boundary of the defined shallow water alert area was too close to dangers off Kirkcaldie Reef.

Safety issue details
Issue number: MO-2009-001-SI-03
Who it affects: All VTS operators
Status: Adequately addressed

Shore monitoring of two-way routes

The REEFVTS monitoring system did not provide an ‘exiting corridor alarm’ when Atlantic Blue exited the two-way route that it was transiting because the route had not been defined as a navigational corridor.

Safety issue details
Issue number: MO-2009-001-SI-04
Who it affects: All VTS operators
Status: Adequately addressed
General details
Date: 07 February 2009   Investigation status: Completed  
Time: 0312 UTC +10   Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): Kirkcaldie Reef, Torres Strait    
State: Queensland    
Release date: 16 December 2010    
Report status: Final   Occurrence category: Incident  
  Highest injury level: None  

Vessel details

Vessel details
Vessel Atlantic Blue  
Flag Hong Kong  
IMO 9332028  
Type of operation Products tanker  
Damage to vessel Nil  
Departure point Singapore  
Destination Townsville, QLD  
Last update 14 November 2018