Summary

Summary

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.