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On 16 December 2010, the ATSB released the findings of its investigation of the 2009 grounding of the piloted tanker Atlantic Blue in the Torres Strait. The Australian Maritime Safety Authority (AMSA) indicated that it was concerned that these findings might point to broader systemic issues affecting the safety of coastal pilotage operations. Notably, AMSA advised that it felt the ATSB was ideally placed to investigate these issues given the ATSB’s independence and investigative powers and that it would be pleased to see the ATSB investigate this matter. The findings of previous ATSB investigations and a number of coastal pilotage reviews also indicated that there may be safety issues. Consequently, the ATSB initiated a systemic safety issue investigation into Queensland coastal pilotage.

The ATSB obtained information for the investigation through a survey of all 82 licensed coastal pilots and submissions from 15 stakeholders, including the two main pilotage providers. Further evidence was obtained by interviewing 22 pilots and meeting all three providers, AMSA and other key stakeholders. Other material taken into account by the investigation included past and present issues of Marine Orders Part 54 (MO 54), the regulatory instrument governing coastal pilotage, as well as previous reviews of the coastal pilotage regime.

The report identifies that under successive issues of MO 54, no organisation(s), including the pilotage providers, has been made clearly responsible and held accountable for managing all the safety risks associated with pilotage operations. This resulted in the effective devolution of responsibility for managing the most safety critical aspects of pilotage to the individual pilots. The report also identifies systemic issues with the potential to affect future safety relating to pilot training, fatigue management, risk event reporting, check pilotage and the utilisation of coastal vessel traffic services. Action has been taken by AMSA to address these safety issues. The ATSB has issued three recommendations to AMSA and two recommendations to each provider to take action to fully address four safety issues.

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