Final Report


What happened

At 0400 on 28 February 2015, a harbour pilot boarded the container ship Maersk Garonne for its passage into Fremantle’s Inner Harbour. The pilotage generally progressed as intended by the pilot until the ship approached the entrance channel 40 minutes later. At this stage, he became concerned that the assisting harbour tugs would not be at the channel’s entrance before the ship.

At 0442¾, the pilot decided to delay entering the channel by taking Maersk Garonne outside (south of) the channel and entering it later. At 0448, the ship grounded in charted shallow water. The ship did not suffer any damage and was re-floated on the rising tide about 3½ hours later.

What the ATSB found

The ATSB investigation found that bridge resource management was not effectively implemented on board Maersk Garonne. As a result, the ship’s bridge team was not fully engaged in the pilotage and did not effectively monitor the ship’s passage. While the master retained responsibility for safe navigation of the ship, the harbour pilot was the only person actively focused on the pilotage. Consequently, single-person errors that occurred went undetected or inadequately challenged and uncorrected.

The investigation identified that Fremantle Pilots’ publicly available passage planning guidance for the pilotage was inadequate and was not effectively implemented. Further, Fremantle Pilots’ pilotage procedures did not include abort points or contingency plans for identified risks.

The investigation also found that procedures for tugs to be on station at the entrance to the port, or for their co-ordinated movement, were not clearly defined.

What has been done

Fremantle Pilots, the port’s pilotage provider, has reviewed and updated its website, procedures and training with respect to pilotage, passage planning and communications. This includes simulator training for emergencies.

Svitzer Australia, the towage provider, has updated its procedures to include defined on-station times for tugs.

Fremantle Ports, the port authority, has advised that it has clarified the role of the vessel traffic service in assisting ship arrivals and berthing.

The safety actions noted above, together with joint simulator exercises, clarify the roles and responsibilities of all parties with respect to monitoring and management of pilotages. This increases safety margins and reduces the likelihood of a similar incident in the future.

Maersk Garonne’s managers have issued fleet circulars to emphasise and clarify the roles and responsibilities of the master and ship’s crew during navigation with a pilot on board. The managers have also implemented a fleet-wide program that includes education and auditing to ensure compliance with bridge procedures.

Safety message

Comprehensive passage planning that includes risk-assessed contingency planning is vital to safe pilotage and underpins effective bridge resource management. The potentially severe consequences of a pilotage accident means that a low accident rate in the past is not a reliable indicator of safety risk.

The occurrence


Safety analysis


Safety issues and actions

Sources and submissions