Marine safety investigations & reports

Contact with wharf by Madang Coast, Townsville, Queensland, on 16 November 2015

Investigation number:
323-MO-2015-007
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

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What happened

At about 2106 Eastern Standard Time, on 16 November 2015, a pilot boarded Madang Coast for its transit into Townsville, Queensland. The master and pilot completed the master-pilot information exchange, which included the berthing plan at Berth 10. As the ship approached the berth, the first line ashore, the forward spring, was looped over a bollard on Berth 10. The forward mooring party made two turns around the first post of the bitts and held onto the spring line. However, shortly after, as weight came onto the line, the line slipped on the post and fell slack.

Madang Coast started moving off the berth towards a ship on the opposite berth. Despite repeated efforts to hold on to the line, it continued to fall slack. Subsequently, Madang Coast‘s bow made contact with the shore end of Berth 10 and its port quarter with the ship on the opposite berth. Both ships sustained minor damage and there were no injuries.

What the ATSB has found

As Madang Coast came alongside the wharf, the forward spring line slipped and could not be used to manoeuvre against. After the spring line slipped, the distance from the stern to the wharf was too far for the aft mooring party to throw any heaving lines ashore. Hence, the stern’s movement away from the wharf continued.

The shipping agent requested a tug reduction for the ship’s berthing. The acting regional harbour master, pilot manager and the ship’s master were all unaware that the agent’s application was made without the master’s knowledge.

The pilotage service did not have documented guidance procedures for berthing or any associated contingencies. The risk management processes were not sufficiently mature nor resilient enough to effectively identify and mitigate risks in pilotage services.

What's been done as a result

The Port of Townsville Limited (POTL) Pilotage Services has completed a review of, and subsequently updated and fully implemented a safety management system (SMS). The SMS included detailed berthing, operations and emergency procedures amongst others. The qualifications and training requirements for licensing pilots for the number of observation, supervised and check trips have significantly increased.

The tug reduction requesting procedure has been updated and now requires a declaration by the ship’s master that an assessment of the intended manoeuvre(s) to and/or from berths have been undertaken.

Safety message

Risk management issues associated with the safe pilotage of ships are commonly known by all parties involved. However, the reality as opposed to the hypothesised scenarios are not always understood nor acted upon. Numerous incidents and their subsequent findings already provide the answers to many of retrospective questions that are asked. Where internal risk management processes may fail to address those questions, forward thinking can. Effective risk management systems and processes can lead to the identification, collation and assessment of found hazards, and, thus, provide the most appropriate mitigation measures.

Download final report
[Download  PDF: 1.6MB]
 
 
Alternate: [Download  DOCX: 1MB]
 

The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Ship details

Appendices

Sources and submissions

Safety Issues

Go to MO-2015-007-SI-01 - Go to MO-2015-007-SI-02 - Go to MO-2015-007-SI-03 - Go to MO-2015-007-SI-04 -

Risk management

The Port of Townsville Limited Pilotage Service risk management processes were not sufficiently mature nor resilient enough to effectively identify and mitigate risks during pilotage.

Safety issue details
Issue number: MO-2015-007-SI-01
Who it affects: All ships entering and departing Townsville under pilotage
Status: Adequately addressed

Contingency planning

The Port of Townsville Limited Pilotage Services’ Pilotage Service Safety Management System did not have documented guidance on berthing manoeuvres nor any associated contingencies.

Safety issue details
Issue number: MO-2015-007-SI-02
Who it affects: All ships entering and departing Townsville under pilotage
Status: Adequately addressed

Tug reduction process

The Port Procedures manual for Townsville allowed shipping agents to request a tug reduction without the knowledge of the ship’s master.

Safety issue details
Issue number: MO-2015-007-SI-03
Who it affects: All ships entering and departing Townsville under pilotage
Status: Adequately addressed

Audit response

The regional harbour master and the pilotage service did not have processes in place to follow up audit findings, to ensure that they were appropriately monitored, actioned and closed out in a timely manner.

Safety issue details
Issue number: MO-2015-007-SI-04
Who it affects: All ships entering and departing Townsville under pilotage
Status: Adequately addressed
General details
Date: 16 November 2015   Investigation status: Completed  
Time: 2200 AEST (UTC +10)   Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): Townsville Harbour, Berth 10   Investigation phase: Final report: Dissemination  
State: Queensland    
Release date: 19 February 2019   Occurrence category: Serious Incident  
Report status: Final   Highest injury level: None  

Vessel details

Vessel details
Operator Consort Express Lines, Papua New Guinea  
Vessel Madang Coast  
Flag Papua New Guinea  
IMO 9135767  
Sector Container  
Type of operation Pilotage  
Damage to vessel Minor  
Departure point Papua New Guinea  
Destination Townsville, Qld  
Last update 15 August 2019