Marine safety investigations & reports

Grounding of the Panama registered bulk carrier Dumun at Gladstone, Queensland, on 29 April 2011

Investigation number:
285-MO-2011-004
Status: Completed
Investigation completed

Summary

Download Final report
[Download  PDF: 3.53MB]
 

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.

 

Download Final report
[Download  PDF: 3.53MB]
 
 
 

Photo

To download, click the link, then right-click and select Save As.

Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations and should be credited accordingly.

Safety Issues

Go to MO-2011-004-SI-01 - Go to MO-2011-004-SI-02 - Go to MO-2011-004-SI-03 -

Commissioning processes

The shipyard commissioning processes did not identify that the ship’s rudder angle indicator transmitter and tiller link-arm were not installed correctly.

Safety issue details
Issue number: MO-2011-004-SI-01
Who it affects: All ship owners, operators, managers, masters and officers
Status: Adequately addressed

Contingency planning

There has not been a comprehensive risk based approach to contingency planning for deep draught bulk carrier operations in Gladstone.

Safety issue details
Issue number: MO-2011-004-SI-02
Who it affects: All pilotage organisations
Status: Partially addressed

Pilotage safety management system

There has not been a comprehensive safety management system implemented in the Port of Gladstone with the aim of identifying, evaluating and controlling pilotage related risk.

Safety issue details
Issue number: MO-2011-004-SI-03
Who it affects: All pilotage organisations
Status: Adequately addressed
General details
Date: 29 April 2011   Investigation status: Completed  
Time: 1706   Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): Gladstone harbour    
State: Queensland    
Release date: 30 July 2012    
Report status: Final   Occurrence category: Incident  
  Highest injury level: None  

Vessel details

Vessel details
Vessel Dumun  
Flag Panama  
IMO 9520819  
Type of operation Bulk carrier  
Damage to vessel Nil  
Departure point Gladstone, Qld  
Departure time 1630, 29 April 2011  
Last update 14 November 2018