Marine safety investigations & reports

Grounding of Bosphorus in the Brisbane River, Qld on 29 October 2013

Investigation number:
304-MO-2013-011
Status: Completed
Investigation completed

Summary

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What happened

At about 2000 on 29 October 2013, the general cargo ship Bosphorus grounded at Lytton Rocks Reach in the Brisbane River after the ship’s helmsman unintentionally put the helm the wrong way.

By the time that the Brisbane Marine Pilot on board the ship realised that the helm had gone the wrong way, it was too late to prevent the ship from grounding in the narrow section of the river. There were no reported injuries, damage or pollution as a result of the grounding.

What the ATSB found

The ATSB’s investigation found that the application of incorrect helm was not identified by the ship’s crew and that the ship’s safety management system documentation provided no guidance in relation to the allocation of function based roles and responsibilities to members of the bridge team during pilotage. 

The investigation also found that the navigational watch was handed over at a critical point of the pilotage and the risks associated with this change were not considered. Furthermore, neither the ship’s safety management system nor the Brisbane Marine Pilots’ passage plan detailed any guidance or instructions relating to handing over the watch or helmsman during high risk areas of the pilotage.

What's been done as a result

Brisbane Marine Pilots has amended their safety management system procedures to address all of the contributing factors specific to pilotage issues detailed in this report. Their risk management team has amended the passage plan specifically related to watch hand overs and changing of the helmsman.

Safety message

While functional roles and responsibilities should always be clearly assigned to each bridge team member, the pilot, the master and the officer of the watch should all check the rudder angle indicator before and after each helm order.

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Safety Issues

Go to MO-2013-011-SI-01 - Go to High risk areas of pilotage - Go to MO-2013-011-SI-03 -

Roles and Responsibilities

Bosphorus’ safety management system provided no guidance in relation to the allocation of function based roles and responsibilities to members of the bridge team during pilotage.

Safety issue details
Issue number: MO-2013-011-SI-01
Who it affects: All persons charged with navigating a vessel during pilotage
Status: Not addressed

MO-2013-011-SI-02

Brisbane Marine Pilots’ ‘Port of Brisbane Passage Plan’ did not detail any guidance or instructions relating to watch handover or changing the helmsman during high risk areas of a pilotage.

Safety issue details
Issue number: High risk areas of pilotage
Who it affects: All persons charged with navigating a vessel during pilotage
Status: Adequately addressed

High risk areas of pilotage

Bosphorus’ safety management system did not detail any guidance or instructions relating to watch handover or changing the helmsman during high risk areas of a pilotage.

Safety issue details
Issue number: MO-2013-011-SI-03
Who it affects: All persons charged with navigating a vessel during pilotage
Status: Not addressed
General details
Date: 29 October 2013   Investigation status: Completed  
Time: 2000 UTC +10   Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): Brisbane    
State: Queensland    
Release date: 22 September 2014   Occurrence category: Serious Incident  
Report status: Final   Highest injury level: None  

Vessel details

Vessel details
Operator Universal Shipping  
Vessel Bosphorus  
Flag Luxembourg  
IMO 9347645  
Sector Other  
Type of operation Pilotage  
Damage to vessel Minor  
Departure point Gladstone, Qld  
Destination Brisbane, Qld  
Last update 14 November 2018