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Final Report

Summary

What happened

At about 0419 on 6 July 2014, in clear visibility, the container ship Kota Wajar collided with the yacht Blazing Keel in Moreton Bay. The ship was southbound in the shipping channel while the yacht was crossing the channel in a southwest direction.

The yacht suffered extensive collision damage but its watertight integrity was maintained. The two persons on board were not injured and the yacht safely returned to its marina.

What the ATSB found

The ATSB found that no one on board either Kota Wajar or Blazing Keel saw or otherwise detected the other vessel before the collision. Neither vessel had maintained a proper lookout in accordance with the international regulations for preventing collisions at sea (COLREGS).

The investigation found that Kota Wajar’s safety management system (SMS) procedures requiring a dedicated lookout were not effectively implemented and a lookout was not posted. In addition, radar was not appropriately used. The high workload of the ship’s bridge team and local conditions, such as background lights ashore, were factors in not detecting the yacht.

The investigation identified that the visual lookout kept by Blazing Keel’s crew was ineffective. Furthermore, the yacht’s night passage was undertaken without radar (which had been inoperational for 18 months) and its diving trip was not properly planned or executed.

It was also found that Brisbane Marine Pilots’ standard passage plan and master-pilot exchange does not ensure that the ship’s bridge team is provided adequate information with respect to local traffic and areas where attention should be paid to small craft.

What's been done as a result

Kota Wajar’s managers, Pacific International Lines, Singapore advised the ATSB that action to better implement SMS procedures with regard to posting a lookout was being taken. Monitoring and verification of compliance with the procedures would be enhanced through unannounced audits, including the retrieval and playback of voyage data recordings. In addition, records of bridge activities, including attendance logs, would be reviewed in detail during routine audits.

Brisbane Marine Pilots (BMP) advised the ATSB that its standard passage plan has been amended to clarify responsibility for maintaining a good lookout by sight and radar. Bridge team engagement and communicating small craft interaction will be emphasised through the master-pilot-bridge team exchange and monitored through BMP’s check pilot system. The pilotage company has also decided to review and amend its pre-arrival information for masters, to emphasise the small vessel interaction risk.

In response to the continuing safety issue around maintaining an effective and proper lookout when navigating in Australian waters, the ATSB has issued a safety advisory notice (SAN) to the masters, owners, operators and skippers of all vessels. Consistent with COLREGS requirements, the SAN reinforces the importance of taking all necessary measures to ensure that a proper lookout is kept at all times, and early avoiding action is taken to prevent collision.

Safety message

Across the past 26 years, investigations into 41 collisions between trading ships and small vessels on the Australian coast have identified that maintaining a proper lookout, using all available means in accordance with the COLREGS, is paramount to preventing collisions. In pilotage waters, pilots have a role in highlighting local traffic areas, patterns and conditions to the ship’s bridge team.

The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

 
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