Marine safety investigations & reports

Grounding of bulk carrier Bulk India, Dampier, Western Australia, on 11 March 2018

Investigation number:
341-MO-2018-004
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

Download final report
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What happened

On 11 March 2018, during departure from Dampier, Western Australia under harbour pilot guidance, the bulk carrier Bulk India experienced an electrical blackout resulting in loss of propulsion and steering control. As a result, the ship exited the channel and ran aground. The ship was recovered into the channel with the aid of tugs, before being taken out the channel, to anchor, for further investigation.

What the ATSB found

The electrical blackout occurred because the auxiliary diesel generator engines shut down after the cooling water temperature controller malfunctioned, resulting in overheated cooling water. The ship’s engineers did not immediately identify the problem and were unable to manually operate the cooling water temperature control valve in time to prevent the blackout.

The ATSB also found that the problems in the engine room started about 13 minutes before the blackout, however the two pilots on board were not informed of the situation. This removed the opportunity for the pilots to prepare for the loss of control, and delayed actions that may have assisted in a more timely or more effective response.

Further, it was found that Bulk India’s emergency generator was not fit for service. When the blackout occurred, the engine started but shut down shortly after, due to overheating. The radiator fan belt had failed several months prior but had not been replaced. The operator, Kowa Marine Service did not have in place adequate procedures to ensure that critical spares were identified and their inventory level maintained, to guarantee availability when required on board.

What's been done as a result

Kowa Marine Service has undertaken a fleetwide program of continual improvement of its safety management and operating systems, and staff education and training processes. This included actions directed at identification, operation, maintenance and spare parts management relating to critical plant and machinery.

Rio Tinto have revised escort towage arrangements for ships departing their facilities in Dampier on the basis of extensive simulation exercises and a review of existing risk assessments. As a result, attendance by a second tug has been extended to number 3 beacons. Further, a comprehensive guidance manual for ship towage operations in Dampier and Port Walcott has been developed.

Safety message

Ship operators and crewmembers should ensure that systems, machinery and equipment, critical to the continued safe operation of the ship, are thoroughly understood, as well as appropriately maintained and tested. This will reduce the likelihood of an emergency situation relating to these items developing and provide a defence against adverse outcomes, should such a situation arise.

Download final report
[Download  PDF: 1.78MB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Additional ship details

Sources and submissions

Appendices

Safety Issue

Go to MO-2018-004-SI-001 -

Critical spares

No procedure or system was in place to ensure critical spares were identified and their inventory controlled to ensure availability when required. As a consequence, the fan belts for the emergency generator had been on order for several months.

Safety issue details
Issue number: MO-2018-004-SI-001
Status: Closed – Adequately addressed
General details
Date: 11 March 2018   Investigation status: Completed  
Time: 1433 WST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): Rio Tinto channel, Dampier   Investigation phase: Final report: Dissemination  
State: Western Australia    
Release date: 11 September 2020   Occurrence category: Serious Incident  
Report status: Final   Highest injury level: None  

Vessel details

Vessel details
Operator Southern Route Maritime S.A. and Nissen Kaiun Co Ltd, Panama  
Vessel Bulk India  
Flag Panama  
IMO 9284271  
Sector Bulk carrier  
Type of operation Iron ore  
Damage to vessel Nil  
Departure point Dampier, Western Australia  
Destination Qingdao, Shandong, People's Republic of China  
Last update 11 September 2020