Jump to Content

Final Report

Summary

What happened

On 15 March, shortly after 2300, Navios Northern Star was transiting the Prince of Wales Channel, Torres Strait, on an easterly heading towards the waypoint north of OG Rock. The coastal pilot’s cue for altering course for the waypoint was to use a radar range from Alert Patches buoy. Shortly after 2314, the pilot ordered starboard rudder for the course alteration.

At about 2316, with the buoy directly ahead, the ship’s master asked the pilot if they were going to collide with it. The pilot then ordered progressive starboard rudder movements in quick succession.

At 2317, as the ship was swinging to starboard, the ship’s port quarter contacted the Alert Patches buoy. Damage to the buoy and ship was limited to paintwork.

What the ATSB found

  • The ATSB investigation found Navios Northern Star’s planned course alteration to pass Alert Patches buoy was not made in time nor was the alteration properly executed and monitored to avoid contacting the buoy.
  • The pilot was using Alert Patches buoy’s radar distance as his primary means to carry out the course alteration, so he remained focused on regaining its lost echo for more than 2 minutes during the critical period before the incident. Further, the master’s challenge to the pilot as the ship closed on the buoy was too late.
  • Bridge resource management techniques were not effectively followed by the ship’s bridge team. They did not have the same mental model of the course alteration as the pilot and they did not actively monitor the pilot’s execution of the alteration.
  • The ship’s voyage plan contained only basic passage information and its bridge team did not know or fully understand the pilot’s planned operational parameters and limits, including wheel over points and safety margins.

Safety message

Safe and efficient pilotage requires the active and continual participation of everyone involved. Pilots and ship’s bridge teams, in particular, need to use the range of available resources and bridge resource management techniques to navigate/conduct the ship. This method significantly increases the opportunity of capturing and managing any errors that may occur.

The occurrence

Context

Safety analysis

Findings

Sources and submissions

Appendices

 
Share this page Comment