What happened
At 1706 on 29 April 2011, the Panama registered bulk carrier
Dumun grounded while
departing the port of Gladstone, Queensland.
Prior to the grounding, the ship's steering appeared
to stop responding to bridge commands when the linkage between the
tiller and rudder angle transmitter became detached. The steering
gear continued to operate normally, but the transmitter lost its
input signal and, as a result, the bridge mounted rudder angle
indicator stopped working.
The bridge team assumed that the steering had failed,
so the pilot ordered the main engine stopped and then started
astern. However, these actions were not enough to prevent the ship
from grounding.
What the ATSB found
The ATSB determined that the ship's builders did not
identify that the rudder angle indicator transmitter and tiller
linkage were not installed correctly. More broadly, the ATSB found
that the analysis of shipping operations in Gladstone, carried out
by the relevant authorities, had not appropriately considered all
that could be done to prevent the grounding of a ship as a result
of steering gear or main engine failure. In addition, it was found
that a comprehensive safety management system had not been
implemented in Gladstone with the aim of identifying, evaluating
and controlling pilotage related risk.
What has been done as a result
Dumun's
shipbuilder has sent a bulletin to the owners of all ships built by
the company advising that the rudder angle indicator linkage should
be checked to ensure that it is correctly fitted. The company has
also modified its procedures to ensure that these checks are
carried out during the building of all future ships.
Maritime Safety Queensland (MSQ) and its pilots have
worked with Gladstone Port Corporation and terminal operators to
improve ships' readiness for departure by implementing rigorous
pre-departure checks. MSQ is also in the process of developing a
single pilotage safety management system covering all of the ports
in which the organisation provides pilotage operations.
Safety message
Safety regulators and port authorities should
consider all the risks associated with the passage of deep draught
ships within their ports and have appropriate contingency plans in
place to deal with foreseeable emergencies.