Safety summary

What happened

At about 1447 on 13 July, a fire started in the engine room of the bulk carrier Marigold, while it was loading a cargo of iron ore in Port Hedland, Western Australia (WA).

Firefighting by the ship’s crew included activating the Halon gas fixed fire suppression system for the engine room. However, a full release of Halon gas did not occur, nor was the engine room effectively sealed. Consequently, the fire continued for about 12 hours until it burnt itself out.

What the ATSB found

The ATSB determined that the fire began on Marigold’s number one generator after a fuel oil pipe fitting on it failed. The resulting spray of fuel oil likely contacted a hot surface on the generator and ignited.

The deployment of the ship’s Halon gas fixed fire suppression system was ineffective, as a full release of Halon gas did not occur and the engine room was not effectively sealed. Failures within the Halon system and multiple failures of the ventilation closing mechanisms were indicative of a lack of effective planned maintenance on board.

The port’s emergency response plan was initiated, but there were misunderstandings between the agencies involved as to the roles of the others during the initial stages of the incident and response. Their emergency plans did not refer to trigger points for transfer of control or include detailed instructions of how to hand over control during an incident.

What's been done as a result

The ATSB has been advised that as a result of this fire and another recent shipboard fire in Fremantle, WA, the State Emergency Management Plan for a Marine Transport Emergency (WESTPLAN MTE) has been revised. The WESTPLAN MTE now covers formal incident controller delegations.

Further, the WA Department of Fire and Emergency Services (DFES), the State’s hazard management agency, has initiated new ‘level 1’ and ‘level 2’ marine firefighting training programs.

The operator of the ship’s berth, BHP Billiton, will now provide international shore connections at its berths to improve water supply to a ship’s fire line in emergencies. Additionally, BHP Billiton has aligned its standardised response checklists with those of DFES. The emergency response plan for shipboard fires will be consistent with these checklists.

Marigold’s managers have taken action to address safety issues with regard to the maintenance and operation of the fixed fire suppression systems and ventilation closing mechanisms.

The ATSB has issued one recommendation to the ship’s managers to further address the safety issue with regard to the operational status of fixed fire suppression systems. It has also issued five recommendations to DFES to address issues related to the shore response to shipboard fires.

Safety message

Response to a large fire on board a ship in port will involve the ship’s crew and shore fire crews. The initial response and fire containment by the ship’s crew requires a thorough knowledge and understanding of firefighting procedures and systems, knowledge which needs to be effectively maintained. Where multiple shore response agencies are involved, their emergency procedures need to be consistent with each other, such that individual and team roles and responsibilities are well understood and ensure that agencies can coordinate an effective response.

The occurrence

At 0145^[1] on 13 July 2014, the 309 m long bulk carrier Marigold (Figure 1) berthed at Finucane Island B berth at Port Hedland, Western Australia. The ship berthed port side alongside to the wharf, with the only access from the starboard side being via the ship’s accommodation ladder. The loading of iron ore cargo started at 0600 with completion of cargo operations expected the next day.

Figure 1: Marigold port side to Finucane Island berth B

Source: Port Hedland Pilots

The chief mate, assisted by the third mate, monitored cargo loading operations from the ship’s ballast control room (BCR) throughout the morning. As cargo loading progressed, the chief mate de-ballasted the seawater ballast tanks. The ship’s number one and number two diesel generators provided electrical power for the ballast pumps and various other shipboard services.

Shortly after 1200, the third mate handed over the cargo watch to the second mate. At about 1300, Marigold’s engineers and engine room ratings met in the engine control room (ECR). The chief engineer assigned them work, which included routine checks in preparation for the ship’s departure from port. To progress the work, they split into three separate work teams (Figure 2).

Figure 2: Plan showing crewmembers locations in the engine room when the fire started

Source: Marigold (annotations by ATSB) 

At 1420, the chief mate needed to use a third ballast pump. The chief engineer started a third generator, number three, to meet power requirements.

Fire detection and initial response

At about 1447, the ship’s fire detection system activated on the bridge and in the BCR and ECR. Soon after, the ship’s fire alarms began sounding throughout the ship and the accommodation fire doors closed automatically. The chief engineer, who was in the ECR with the second engineer and oiler 2, checked the fire detection panel, which indicated detectors had activated in the engine room. He went to investigate and saw smoke and flames coming from the generator flat (engine room deck 3).

Figure 3: Aerial view showing Marigold at Port Hedland 

Source: Google earth (annotated by ATSB) 

He attempted to extinguish the fire using a portable fire extinguisher but could not get sufficiently close because of the smoke. He returned to the ECR and phoned the duty seaman on the bridge, confirming there was a fire in the engine room.

Meanwhile, after the chief mate checked the fire detection panel, he stopped the ballast pumps and left the BCR to investigate the fire alarms. He tried to descend the internal stairs from the boat deck to the upper deck and enter the engine room. However, thick black smoke was building up quickly, so he left the accommodation and proceeded out onto the boat deck.

At the same time, the second mate went to the ship’s bridge, where the master joined him. The duty seaman relayed the information he had received from the chief engineer, confirming a fire in the engine room.

At about 1448, the master sounded the general emergency signal, while the second mate instructed the wharf supervisors to stop cargo operations. 

The second mate then announced over the ship’s public address system that there was a fire in the engine room and directed all crewmembers to their muster stations.

Meanwhile, audible fire alarms alerted the first engineer, who was on the engine room bottom plates. He instructed his team to leave the engine room using the lift. He could now smell smoke and decided to locate the seat of the fire.

About the same time, on deck 3, the third engineer and oiler 1, also alerted by the audible fire alarms and the smoke, began making their way out of the engine room. The third engineer found his way to the ECR but the oiler became disoriented in the smoke and took an alternative route to exit the engine room.

Call for shore-side assistance

At 1450, the master reported the fire to the Port Hedland shipping control tower (SCT) and asked for immediate assistance. He also contacted the ship’s local agent and requested firefighting teams to assist.

In the SCT, the duty vessel traffic services officer (VTSO) began coordinating an emergency response. He requested the Western Australian Department of Fire and Emergency Services (DFES), BHP Billiton emergency services, Port Hedland pilots, harbour tugs and the local police to respond to the emergency.

By this time, the third mate had joined the master on the bridge. Meanwhile in the engine room, the first engineer had reached deck 3, but could see little in the dense smoke. He ascended a nearby ladder and managed to locate the ECR windows. He banged on the windows to attract attention, until the men inside pulled him in through the ECR door.

At about 1453, the chief, first, second and third engineers and oiler 2 left the ECR through the aft fire door into the steering gear room. By now, the disoriented oiler 1 had ascended several ladders searching for an exit from the engine room.

At about 1456, several crewmembers gathered fire hoses from the fire control room (FCR) and started preparing them on the upper deck for boundary cooling.^[2] Shortly after, oiler 1 came out through an exit between the funnel housing and accommodation block on the upper deck, where he was met by crewmembers.

By now, the chief, first, second and third engineers and oiler 2 had ascended the exit ladder from the steering gear room, out on to the upper deck, aft of the funnel housing.

Meanwhile, three harbour pilots reported into the SCT. Upon sighting smoke issuing from Marigold’sengine room and accommodation, two pilots left the SCT and proceeded to the pilot boat for transfer to the ship.

At about 1457, following a head count, Marigold’s chief mate reported to the master that all crewmembers were present.

Shortly after,the master told the chief mate to close all fire and smoke dampers^[3] and shut down the generators. He relayed the instructions to the mustered crewmembers, and several of them started closing the dampers. The chief engineer then operated the fuel oil quick-closing valves^[4] (QCV) from the FCR on the upper deck.

At 1501, all three diesel generators shut down and electrical power was lost. Shortly afterwards, the emergency generator started and restored power to the emergency switchboard.

At about this time, DFES’ Pilbara superintendent dispatched the acting area officer (AO) from Karratha to Port Hedland, (about 245 km away).

Meanwhile, the crewmembers continued to close the dampers, and about 30 minutes after the first fire alarm, the chief mate reported to the master that all engine room dampers and QCVs were closed. He then took another head count and confirmed all crewmembers were accounted for.

Control attempts

At 1517, the master told the chief mate to activate the engine room Halon gas fixed fire suppression system (Halon system). The chief mate and chief engineer entered the FCR and activated the system.

At about 1520, six BHP Billiton emergency services officers (ESOs) and two South Hedland Volunteer Fire and Emergency Services (VFSR) firefighters arrived at the Finucane Island north gate (Figure 3) in support vehicles and fire appliances. Once on the wharf, they started preparing fire hoses and firefighting equipment.

Meanwhile, the two harbour pilots boarded Marigold from a pilot boat. The master briefed the pilots on the bridge about the situation, where one of them remained to assist with ship-shore communications.

The other pilot went down to the upper deck to provide on-scene updates and assist the crewmembers. Upon his arrival, the chief engineer briefed the pilot about the situation and informed him that he had activated the Halon system. The chief engineer opened the Halon room door to show the pilot, but the room was full of gas and prevented entry, so he closed the door.

Nearby, the crewmembers had mustered forward of the accommodation and two of the crewmembers appeared to be suffering from smoke inhalation. Seeing them, the pilot requested his colleague on the bridge to ask the SCT to send medical assistance.

At 1525, one harbour tug (Figure 4) started boundary cooling and another tug started pushing the ship onto the wharf. Consequently, the master informed the chief engineer to stop the emergency generator and close its dampers to prevent water spray from entering its air intakes.

Figure 4:  Harbour tug boundary cooling the engine room

Source: Port Hedland Pilots

At about this time, the BHP Billiton emergency services supervisor (ESS) arrived at Finucane Island north gate. The senior ESO and senior VFRS firefighter briefed him and he then assumed the role of the shore response on-scene incident controller (IC). There was no access to the ship from the wharf because the shore gangway at that berth was not operational at that time. Hence, the pilot on the upper deck briefed the IC regarding the on board situation via VHF radio.

At 1535, the South Hedland VFRS senior firefighter advised the AO that there was a fire in the ship’s engine room and the crew had released Halon into it. Although the crew had closed all engine room dampers there was still a lot of smoke coming from them. Subsequently, the senior firefighter informed the IC that the AO from Karratha was expected at the scene at 1730.

The IC sent an ESO to board the ship via a workboat to attend to the smoke-affected first engineer and oiler. Meanwhile, the ship’s crewmembers assisted other ESOs (who were on the wharf setting up fire hoses) with the transfer of a fire hose up and on to the ship’s upper deck. Shortly after, the duty Port Hedland volunteer fire services (VFS) firefighter arrived on the wharf with additional equipment.

At about 1550, the ESO completed preparations for the medical evacuation of both smoke-affected crewmembers. The Port Hedland pilot transfer helicopter evacuated the injured crewmembers from the ship and transferred them to the local hospital for treatment.

At 1610, four ESOs boarded Marigold via a launch, using the ship’s aft accommodation ladder. A third harbour pilot, from a nearby ship also boarded to assist with communications. Once on board, the ESOs and two pilots set up a staging area near the accommodation block on the upper deck and planned an engine room entry.

Meanwhile the AO had contacted the DFES regional command and discussed the situation. They decided that as the ship’s crewmembers had discharged the Halon gas into the engine room, it was to remain closed for 72 hours, boundary cooling was to be maintained, and temperatures monitored. Additionally, DFES specialised ‘vessel entry’ firefighters were mobilised to leave Perth (about 1,650 km from Port Hedland) on a flight the next day. The AO phoned the IC and gave him this information.

At 1648, the IC tasked two ESOs to take bulkhead temperature readings around the engine room, but not to enter it. Wearing breathing apparatus (BA) and carrying a charged fire hose, they descended into the steering gear room and started taking temperature readings. As they moved around the steering gear room, they passed through two open fire doors and entered the ECR, where they recorded temperatures of up to 100 °C. They did not investigate the engine room any further.

Shortly after, the IC withdrew the ESOs from the ECR and the ship’s master decided to disembark non-essential crewmembers using a launch to transport them ashore.

At about 1730, the AO arrived at the berth and the IC updated him on the situation. Shortly after, the ESOs reported smoke and a possible secondary fire in the engine room. The tugs maintained boundary cooling.

At about 1758, the pilots advised Marigold’s master that the ship’s mooring lines would need to be tended with the rising tide. Without electrical power, crewmembers would need to manually handle the lines, so the master arranged for them to return to the ship.

At 1820, the ESOs reported that temperatures had stabilised, however, smoke emissions from the engine room soon increased again.

At 2004, the AO took over as IC from the ESS. Subsequently, the ESS assigned the IC an ESO (also a South Hedland VFRS fire fighter) as the on-scene BHP Billiton liaison officer. Shortly after, both the AO and ESO boarded Marigold and began an assessment.

At 2116, the ESOs reported increasing temperatures again and heavy smoke from the engine room. The IC called the SCT and asked that 20 m3 of CO2 be delivered to the ship for use in the engine room to suppress the fire. Consequently, the Port Hedland harbour master liaised with the BHP Billiton emergency services shore management to organise the CO2.

At 2233, Marigold’s master and chief engineer, accompanied by the IC and two pilots, inspected the Halon room. They found that one of the two banks of Halon bottles had partially released while the other bank had not discharged at all. They also found that only one of the two Halon gas distribution valves to the engine room had opened. The chief engineer tried manually releasing the remaining Halon bottles into the engine room, but he was unsuccessful.

Shortly after midnight, the IC and a pilot entered the steering gear room wearing BA. They found both fire doors leading into the ECR open and closed them to better seal the engine room. Boundary cooling continued throughout the night and temperatures remained steady.

Transition to recovery

At 1330 on the following day, 14 July, the specialised DFES ‘vessel entry’ firefighters boarded Marigold. They confirmed that the fire had burnt out and, hence, the previously arranged CO2 was not required. The AO then handed the IC responsibility to a senior ‘vessel entry’ fire fighter.

At 1912, the ‘vessel entry’ firefighters inspected the engine room and found significant damage to number 1 generator and all electrical systems and wiring. Additionally, most of the switchboards in the generator flat and ECR were damaged beyond repair, making the other two generators inoperable.

Marigold’s accommodation block had considerable smoke damage throughout, rendering the crew accommodation uninhabitable.

Later that evening, DFES firefighters re-assessed the situation and informed the ship’s master that they considered it safe to start the emergency generator.

Figure 5: Marigold departing Port Hedland under tow

Source: Port Hedland Pilots

At 2000 on 15 July, DFES officers completed atmosphere testing in the accommodation and engine room. They determined that persons entering those spaces needed to wear respiratory equipment.

At 1045 on 16 July, DFES’s IC handed over charge to the Port Hedland harbour master. It was then decided to move the ship to an anchorage.

On 17 July, the harbour master arranged for two shore generators to be placed on the ship to power its steering gear, mooring winches, and temporary lighting.

At 1330 on 19 July, Marigold was shiftedto an anchorage with eight tugs in attendance while awaiting towage to a suitable port for repairs.

On 23 July, Marigold was towed from the anchorage, bound for Singapore for repairs (Figure 5).

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1. All times referred to in this report are local time, Coordinated Universal Time (UTC) + 8 hours.
2. Cooling of the structure around the fire origin to lower the temperature and reduce heat transfer to adjacent compartments.
3. A damper is a device installed in a ventilation duct, which under normal conditions remains open allowing flow in the duct, and is closed during a fire, preventing the flow in the duct to restrict the passage of fire.
4. Remotely operated pneumatic quick closing valves used to shut off the fuel supply to machinery in case of emergency.

Context

Marigold

At the time of the fire, Marigold was registered in Panama, classed with the Korean Register of Shipping (KR) and managed by Korea Leading Company of Ship Management (KLCSM), South Korea. Including the master, the ship had a crew of 23 Korean and Burmese nationals.

The master had 30 years of seagoing experience, including 12 years as master on large bulk carriers. He had joined Marigold about 2 months before the incident.

The chief engineer had 40 years of seagoing experience, including 26 years as chief engineer on large bulk carriers. He had sailed as chief engineer on board Marigold about 8 years previously and re-joined the ship about 2 months before the incident.

The chief mate had 25 years of seagoing experience, including 10 years as chief mate and held a chief mate’s certificate of competency. He had sailed on a sister ship to Marigold for 8 months and joined Marigold 2 months before the incident.

Diesel generators

Marigold was equipped with three SsangYong MAN B&W medium speed, turbocharged, six cylinder diesel engine-driven generators. The generators were located at the aft end of the engine room, on deck 3, directly below the ECR. They each provided 650 kW of electrical power.

Figure 6: Diesel generator fuel oil supply system

 Source: SsangYong instruction manual, annotated by the ATSB

At the engine, a low-pressure gear pump circulated fuel through a fuel filter to the main fuel oil injection pumps. Two pressure gauges (marked ‘A’ and ‘D’ in Figure 6) indicated the fuel oil pressure before the fuel pump and fuel oil pressure before the engine.

Halon system

A Halon 1301 fixed fire suppression system (Figure 7) protected Marigold’s engine room. Halon 1301 (Halon), the common name for bromotrifluoromethane, is a colourless, odourless gas with low toxicity and a density about five times that of air. Halon does not extinguish fires through oxygen starvation, but inhibits the chemical process in which a substance reacts rapidly with oxygen and gives off heat. It has excellent fire extinguishing properties and is a clean agent because it leaves no residue, but it has a high ozone depleting potential.

The Halon was stored under pressure (42 bar^[5]), as a liquid, in two banks of 130 L^[6] bottles in the Halon room, located on the port side of the upper deck (Figure 2).

Release of Halon from the bottles and operation of the distribution valves utilised a carbon dioxide (CO2) pilot system. The pilot CO2 bottles were located in identical control boxes in the Halon room and the fire control room (FCR).

When an operator opened the door of a control box, a switch activated audible and visual alarms in the engine room and stopped the ventilation supply and exhaust fans. Next, the operator opens the pilot CO2 bottle valve and CO2 flows to pneumatic actuators, which open the main distribution valves prior to the release of Halon. As the main valve spindle rotates, a pilot valve fitted to the spindle also opens, allowing the CO2 to flow to, and activate the Halon bottle release valves. The bottles simultaneously discharge the Halon, as a gas, into a common manifold system, discharging into the engine room via the distribution valves and pipework.

Figure 7: Marigold’s Halon fire suppression system

Source: ATSB

The Halon system operating instructions displayed in the Halon room and FCR stated:

Once the fire was extinguished, no one is to enter the engine room, until it was certain that there is no danger of re-ignition.

In 1987, the Montreal Protocol prohibited the use of ozone depleting gasses. These measures were adopted in SOLAS,^[7] which then prohibited:

full-scale tests of Halon fire-extinguishing systems (from January 1992)

installation of Halon fire-extinguishing systems on board ships (from 1 October 1994).

However, SOLAS did not specify any phasing-out requirement for Halon fixed fire extinguishing systems on existing ships. Some flag administrations provided instructions for decommissioning and replacement requirements for existing halon system. However, Marigold’s flag State at the time of the fire (Panama) had no such requirements.

Firefighting equipment (FFE) maintenance

A merchant marine circular^[8] issued by Panama details the minimum recommended levels of maintenance and inspection requirements for FFE. This circular and the manufacturer’s guidance formed the basis of Marigold’s FFE maintenance procedures.

Testing and inspection

Testing and inspection of FFE was conducted at scheduled weekly, monthly, quarterly, annual, biennial, five-year and ten-year intervals. Trained personnel (either ship’s crewmembers or service technicians) carried out the equipment testing and maintenance. Marigold’s planned maintenance system (PMS) assigned the chief mate responsibility for the inspection and maintenance, and the chief engineer responsibility for controlling the equipment.

The PMS included testing of the following:

• fixed gas fire-extinguishing system
• fire doors
• ventilation systems (several types of mushroom ventilators were fitted and were closed by either rotating the ventilator head down with a hand wheel or by turning a fire damper handle connected to the damper flap inside the ventilator trunking)
• fire dampers (closure of the main engine room dampers required a wire connected via pulleys to the dampers blades to be pulled)
• remote closure of engine room hatch (a hand chain block suspended from the funnel housing bulkhead was used to lift and open the engine room hatch).

On board emergency response

Chapter III, Regulation 8 of SOLAS, Muster list and emergency instructions, requires ships to have:

• clear instructions for every person on board to be followed in the event of an emergency
• muster lists exhibited in conspicuous places throughout the ship, including the navigating bridge, engine room and crewmembers’ accommodation spaces.

Marigold’s muster list specified details of the general emergency signal and public address system, and additionally, crewmembers’ duties when the emergency alarm sounded. Each crewmember was allocated an emergency duty based on rank and was assigned to the command teams or an on-scene team. The command teams mustered on the bridge and in the engine control room, with the master in overall command.

The on-scene team was comprised of two fire teams and an assistance party. The chief mate was the leader of fire team one and was in charge of the fixed fire-fighting system. Fire team ‘one’ was the primary firefighting team outside of the engine room. The first engineer was the leader of fire team ‘two’ and was in charge of isolating the electric power supply, mechanical ventilation and the emergency fire pump. Fire team ‘two’ was the primary firefighting team in the engine room. The second mate was the leader of the assistance party and in charge of first aid and medical treatment.

Additionally, Marigold’s safety management system (SMS) contained emergency response procedures (ERP).The ERP detailed the on board emergency response to be followed by crewmembers for engine room fires, including the use of fixed gas suppression systems.

Training and familiarisation

Marigold’s SMS also required each crewmember to complete an on board familiarisation. Upon joining the ship, each crewmember had to be familiar with their emergency duties before the voyage began. Additionally, within 2 weeks, they had to complete on board training in the use of all firefighting equipment (FFE). The training covered fire party duties, location of the muster station and an overview of the engine room fixed firefighting system.

Further, the company specified that the ship’s crewmembers conduct monthly fire drills, in accordance with SOLAS requirements. The ERP listed 15 fire scenarios and required crewmembers to use a different scenario for each drill. Among others, the scenarios included simulated fires in the accommodation and engine room.

Fire boundary and isolation

Thermal and structural boundaries divided Marigold’s spaces into vertical and horizontal zones. SOLAS classified these spaces according to their fire risk. Consequently, fire integrity standards applied to the boundaries, which formed the divisions between the adjacent spaces. The space classification determines the materials used to construct the solid divisions and openings therein.

The objectives of the fire boundaries defined by SOLAS were to:

• prevent the occurrence of fire and explosion
• reduce the risk to life caused by fire
• reduce the risk of damage caused by fire to the ship, its cargo and the environment
• contain, control and suppress fire and explosion in the compartment of origin
• provide adequate and readily accessible means of escape for passengers and crewmembers.

Port Hedland

Port Hedland (Figure 8) is Australia’s largest bulk cargo port. It is located on the north-west coast of Western Australia and services the mineral rich Pilbara region. The port has 16 berths, including 12 privately owned iron ore berths, and a single shipping channel. 

The port’s major export commodity is iron ore. In the financial year ending 30 June 2014, more than 372 million tonnes of iron ore was exported on over 2,500 ships.

Pilbara Ports Authority (PPA) is responsible for the safety and efficiency of shipping in the port and its waters, for which it has overall responsibility for planning and development.

Figure 8: Port Hedland

Source: ATSB

Shore response to a shipboard fire

In Western Australia, the management of a marine transport emergency within port boundaries involves multiple agencies with overlapping responsibilities. The agencies include the Department of Transport, Western Australia (DoT), the port authority, the marine export facility owner, DFES and the ship’s master. The DFES recommends that a unified command structure^[9] be used by agencies responding to an incident.

The WESTPLAN MTE^[10] states that the port authority and the marine export facility owner perform the immediate response activities for a marine transport emergency (MTE)^[11] within port boundaries. These organisations provide the IC^[12] and act as the controlling agency.^[13]

Additionally, DoT is the hazard management agency (HMA)^[14] for any MTE that occurs in all waters within the State. However, DFES assumes responsibility for incidents involving fire and any rescue that results from it.

The DFES only provides the IC if the incident requires a multi-agency response, or if requested by a port authority or the marine export facility owner. In instances of an incident requiring a multi-agency response, the IC is a suitably trained and qualified DFES officer. A comprehensive handover is required between the immediate response IC and the relieving DFES IC.

Port marine safety plans

All port authorities and private companies operating ports^[15] in Western Australia under the Port Authorities Act 1999 are required to prepare, maintain and implement a ‘marine safety plan’. These plans identify arrangements for managing MTE situations within port waters.

Hazard management structure/arrangements

When an MTE involving a ship fire is declared, the DFES has overall responsibility for control and coordination through the appointed IC. The IC will be a suitably trained and qualified officer from DFES, the port authority, or the maritime export facility owner.

PPA

The PPA maintains an emergency response plan (ERP). The objective of the ERP is to provide the DoT or DFES (as the HMA), with assistance, coordination and marine expertise to manage the incident. The plan provides guidance for the initial response and recommended remedial action to an emergency within the port limits.

There are three levels of response to incidents within PPA’s jurisdiction:

• ‘level 1’ - can be resolved through the use of local or initial response resources only
• ‘level 2’ - requires deployment of resources beyond the initial response
• ‘level 3’ - requires multi-agency responses for effective management of the situation.

When a ship berthed in Port Hedland requires emergency assistance, the ship’s master is required to contact the SCT.

The duty vessel services traffic officer (VTSO) in the SCT then notifies a number of pre-identified parties, including:

• Port Hedland harbour master
• Port Hedland safety & security officer
• duty pilot

DFES (on ‘000’).

Additionally, PPA’s ERP provides the following guidance for a fire on board a berthed ship:

The VTSO will also advise the local tug operators, pilot helicopter crew, and medical services an emergency exists and that they are required to standby for further instructions.

The Harbour Master will attend the SCT to co-ordinate the emergency response and the Duty Pilot will assist. Additionally, another senior marine pilot will proceed to the ship to assist the response coordination and provide updates to the SCT.

The Harbour Master will deploy suitably equipped tugs to assist with firefighting. The local VFRS officer will be on board a tug directing firefighting operations.

Throughout, the ship’s master maintains responsibility for fighting fires on ships alongside berths, until the arrival of a Senior Fire Officer. The Senior Fire Officer will then assume overall direction of all available firefighting equipment, including the direction of the tug firefighting resources.

Marine export facility owner

The maritime export facility owner, BHP Billiton, also maintains an ERP. Under an agreement with the HMA, the BHP Billiton security and emergency management (SEM) teams will assist with shipboard emergencies at BHP berths.

The SEM supervisor (ESS) is the designated on-scene IC and is in command of the overall operations at the incident scene, including:

• developing and coordinating a strategic plan to combat the crisis or emergency
• ensuring that there are adequate resources available
• ensuring that operations are carried out safely and in line with procedures and protocols
• liaising with other emergency agencies.

Under the IC’s direction, ESOs are responsible for the following:

• leading the first response team (FRT) actioning the strategic plan
• assessing medical response needs, and administering first aid/medical treatment
• ensuring emergency resources are ready and available.

DFES

The DFES response to an MTE is determined by the location of the incident and capabilities of the first arriving response unit. In regional ports (Figure 9) such as Port Hedland, the port authority is the first response agency (FRA) and DFES’ volunteers provide fire services for marine fires. There is a heavy reliance on FRA’s across most of WA.

The VFRS firefighters are stationed in South Hedland and a VFS firefighter is stationed in Port Hedland (both with designated marine fire roles). All VFS and VFRS firefighters are trained in marine fire assessment and containment (MFAC)^[16] techniques. The ship firefighting cache^[17] in Port Hedland is used to support land-based marine fire responses. The DFES operations command unit in Karratha provides for the Pilbara region. Specialised ‘vessel entry’ firefighters or marine fire assessment and suppression capability (MFASC)^[18] brigades can also be deployed to regional ports. However, MFASC brigades are based in metropolitan areas (such as Perth) and comprise professional career firefighters. The brigades are provided the training and equipment to fight shipboard fires in port or at sea.

Figure 9: Regional first response agencies

Source:  WESTPLAN MTE

DFES’ Marine Fire Emergency Response Guide (MFERG)

The MFERG provides the first arriving DFES IC guidance to establish firefighting strategies and recording incident information. The guide contains the following information:

• decision model for vessel fire attack
• ship fire response check list
• temperature monitoring for ship fires
• temperature monitoring maps for ship fires
• draft mark recordings for vessel trim and list.

Before committing any resources to firefighting or other duties, the IC is required to conduct a dynamic risk assessment and decide an attack strategy, using offensive or defensive tactics.

DFES’ marine firefighting training

When DFES is asked to attend a shipboard fire, it is likely that the fire has progressed beyond the normal capabilities of the ship’s crew. Therefore, DFES firefighters are trained in specific areas of fighting marine fires applicable to their designated roles:

• marine fire assessment and suppression capability (MFASC)
• marine fire support (MFS)^[19]
• marine fire assessment and containment (MFAC).

The DFES Marine Firefighting Capability and Training manual referenced engine room fires. In all events, restriction of oxygen flow to the fire was required, and for serious fires, the use of fixed firefighting installations was to be considered. The manual stated:

The use of fixed installations is unlikely to be effective if its introduction is delayed for an excessive period of time, due to high temperatures building up in the engine room compartment.

After flooding an area with CO2, the area should be left closed for sufficient time to allow the burning materials to cool below their ignition temperature.

Additionally, prior to entry into the affected spaces, three successive significant temperature reductions across all boundaries were required. The last temperature reduction at the hottest boundary needed to be a reading below 50°C. Further, readings returning to ambient temperature were indicative of the fire being extinguished.

The manual also indicated that generally, if a fire involved cable insulation and lagging, a longer period would be required before the heat dissipated, as these materials may continue to smoulder for some time.

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5. One bar equals 100 kPa or approximately one atmosphere.
6. 130 litres equates to 139 kg of Halon liquid.
7. The International Convention for the Safety of Life at Sea, 1974, as amended.
8. MMC 281 - Guidelines for the Maintenance and Inspection of Fire-Protection Systems and Appliances.
9. Unified Command is a supporting principle to the Australasian Inter-service Incident Management System (AIIMS), which requires the inclusion of key decision makers from all combat agencies. The location of the vessel will determine which jurisdiction has responsibility for it, and what emergency response is appropriate.
10. The State Emergency Management Plan for a Marine Transport Emergency 2011 (WESTPLAN MTE) details responsibilities, response, and recovery from MTEs in Western Australian Waters.
11. Marine Transport Emergencies, whatever their cause, may threaten or endanger life, property and/or the marine environment and require the coordination of a number of significant emergency management activities.
12. The incident controller is the person who has the overall control of the incident scene. The IC has responsibility for determining the desired outcomes for the incident response and the management of response activities to achieve those outcomes.
13. An agency nominated to control the response activities to a specified type of emergency.
14. An agency designated to lead the response to emergencies in relation to the type of hazard for which it is prescribed.
15. Five port authorities under the Port Authorities Act 1999 - Fremantle Ports Authority (Port of Fremantle), Southern Ports Authority (Albany, Bunbury and Esperance), Mid West Ports Authority (Geraldton), Pilbara Ports Authority (Ashburton, Dampier and Port Hedland), Kimberley Ports Authority (Broome).
16. Volunteer team that initial responds to a marine fire incident alongside and has the appropriate training and equipment to assess the incident complexities and contain the fire by securing any holds, cabins or parts of the ship until additional expertise is mobilised
17. Equipment that mainly consists of couplings, spanners, connections and specialised thermometers to enable DFES firefighters responding to a shipboard fire. This cache is stored locally at the port.
18. Professional team that is an initial response to a marine fire incident either alongside or at sea and has the training and equipment to suppress that fire. This includes procedures, specialist equipment and adequate initial response and back up crews.
19. A firefighting team that is fully conversant with supporting a marine fire alongside, and is able to back up a MFASC Brigade, and has the training and understanding of equipment. These teams are not expected to enter interior areas on a burning vessel.

Safety analysis

The fire

On 13 July, while Marigold was loading cargo in Port Hedland,a fire started in the ship’s engine room. The fire began on the ship’s number one generator after a fuel oil pipe fitting on it failed. The resulting spray of fuel oil likely contacted a hot surface and ignited.

The firefighting response included deploying the ship’s Halon fixed fire suppression system. However, a full release of Halon gas did not occur and the engine room was not effectively sealed. Consequently, the fire continued for about 12 hours until it burnt itself out.

Fuel oil pipe fitting failure

The generator’s fuel system pressure gauge piping originally consisted of continuous steel pipe connecting the fuel line to the pressure gauge. However, at some time in the past, a different type of pressure gauge had been fitted to the piping (fuel oil pressure before the engine). While the replacement gauge had a similar back mounting arrangement to the original, its connection fittings were incompatible with the original pipework, and it could not be directly connected to the piping. Therefore, the gauge had been connected to the original steel pipe using a section of copper pipe and a compression fitting (Figures 10 and 11).^[20]

Figure 10: Comparison between generator pressure gauges and gauge pipework

 
Source: ATSB

Although the steel and copper pipes had the same nominal internal diameter, they had different outer diameters. Consequently, when the compression fitting was tightened, it is likely that the steel pipe was not adequately secured, and it separated from the fitting in the time leading up to the fire. The resulting spray of pressurised fuel oil produced a thin oil film that spread over a large area (Figure 11). It is likely that the oil film contacted a hot surface on the generator and ignited, resulting in a fire around its turbocharger.

Figure 11: Fuel oil spray from compression fitting

Source: ATSB

On board response

Evacuation via engine room lift

On 13 July, when alarms indicating the engine room fire sounded, the first engineer and three crewmembers were on the bottom plates - the lowest level of the engine room

The first engineer ordered his team to evacuate using the engine room lift. The lift accommodated only three persons, so the first engineer ascended the engine room ladder to make his exit (Figure 12).

Figure 12: Engine room lift and adjacent ladder

It is universally accepted practice not to use a lift in an emergency due to the unacceptably high risk of becoming trapped in the lift if the power fails. Safety placards on the lift doors also warned ‘Caution, lifts are not be used in the event of an emergency’. The crew took an unnecessary risk by using the lift.

Fire isolation and oxygen starvation

Containing a shipboard fire in the space where it starts requires the integrity of thermal and structural boundaries to be maintained. Further, limiting the fire growth potential in the space relies on preventing or restricting the air supply to it.

Openings in the structural boundaries in accommodation and machinery spaces are fitted with fire doors (those in the accommodation are usually self-closing). The doors are designed to provide a restriction to the passage of smoke and flame equivalent to that of the division in which they are fitted. Fire doors fitted in boundary bulkheads of machinery spaces shall be gastight and self-closing. Regulations require that self-closing doors are not fitted with hold-back hooks.^[21] However, hold-back arrangements fitted with remote release devices of the fail-safe type may be utilised.

Structural boundary close down

All fire doors on board Marigold should normally have been in a closed position. However, ATSB investigators found the fire door leading to the engine room from the upper deck inside the accommodation had been tied open (Figure 13).

Figure 13: Fire door tied open

Source: ATSB

Closedown of the engine room ventilation

At about 1457, Marigold’s master ordered all engine room ventilation isolations closed. Over the next 20 minutes, crew went about closing mushroom ventilators, fire dampers and the engine room hatch.

However, a number of mushroom ventilators and dampers could not be fully closed. The closing mechanisms of these openings were difficult or impossible to operate – indicative of inadequate maintenance of this critical equipment over an extended period. Consequently, the engine room was not effectively isolated; smoke continued to billow from the openings, and air entering the engine room sustained the fire (Figure 14).

Figure 14: Smoke billowing from engine room ventilators

Source: PPA

The continuing flow of air to the fire was further exacerbated by an inability to close the engine room hatch. Heavy smoke prevented the crew from reaching the chain block used to hold the hatch open.

At 1517, although the engine room was not effectively isolated, the chief mate reported that it had been closed down. Hence, the master ordered Halon gas released into the engine room. While the Halon gas may have suppressed the fire had the engine room been sealed, its impact was limited due to the openings and fire doors that were not closed.

Loss of electrical power

In response to the fire, Marigold’s main generators were stopped. The emergency generator then started, providing power for emergency services, including a fire pump, lighting and essential services.

A short time later, a harbour tug started boundary cooling the ship’s engine room. The master was then advised that the ship’s fire pump was not required for boundary cooling. Consequently, he asked the chief engineer to stop the emergency generator and close its air intakes. From this time onwards, the ship had no electrical power and was unable to effectively support the firefighting.

Halon system

Main distribution valve failure

On the master’s orders, the chief mate and chief engineer entered the FCR and operated the Halon system to release gas. However, unbeknown to them at the time, a full release of the gas did not occur.

During their investigation on board the ship, ATSB investigators found only one of the two main distribution valves had opened. This meant that the pilot CO2 system had only activated the Halon gas bottles of ‘bank 2’ (Figure 15). Therefore, there was only a partial release of Halon gas into the engine room.

The ATSB identified a number of possible reasons for ‘bank 1’ main distribution valve not opening, including the:

• pilot CO2 gas bottle had insufficient pressure
• pilot CO2 gas bottle was not left open for sufficient time
• pilot CO2 gas bottle was not fully opened/could not be fully opened
• pilot CO2 gas piping was leaking and sufficient gas leaked out to cause the partial failure.

Halon gas bottle valve failures

The pilot CO2 gas flowing via the open distribution valve should have activated the release valves of all the Halon bottles. However, several bottle release valves failed to activate. Further, when the chief engineer manually activated every bottle on each bank, several release valves also failed to activate (Figure 15). Investigators later found that individual bottle pressure gauge readings across the two banks varied across a wide range (0 to 50 bar).

Figure 15: Halon bottle pressures after release

Source: ATSB

The ATSB investigation identified a number of possible reasons for the failure of the Halon gas bottles to discharge, which include:

• inaccurate bottle pressure gauges
• insufficient bottle charge (low pressure)
• failure of bottle release valves to operate
• holed (leaking) individual pilot CO2 flexible hoses.

System operation and awareness

Marigold’s SMS procedures required the crewmembers responsible for the Halon system to be familiar and competent in its operation.

At interview, both the chief engineer and chief mate stated that they understood the system, when activated, was designed to release only half of the Halon bottles. They indicated that the fixed fire suppression systems on ships they had previously sailed on had operated in this manner. However, Marigold’s Halon system was designed to release 100 percent of the gas bottles when activated.

At about 2200, with smoke emissions increasing, the pilots inspected the Halon room and found approximately half the Halon bottles had been activated. However, one distribution remained in the closed position. They informed the IC and Marigold’s master and a further inspection of the Halon system was undertaken. It was concluded that the system had not functioned as intended. The master then ordered that the remaining bottles be manually discharged.

In following the master’s instruction, the chief engineer started removing the bottle head release pins and discharging each bottle into the main manifold. However, as the main distribution valve from bank ‘1’ had failed to open and was still closed, the manual release of Halon gas over-pressurised the manifold and relief lines. These lines were in a heavily corroded, poor condition and the over-pressure condition caused the failure of the lines’ pressure relief system, allowing Halon gas to disperse into the atmosphere (Figure 16).

The investigation also identified that the main distribution valves were designed so that they could be manually opened whether or not the line was pressurised.

Therefore, a secondary method of operating the system was available. However, none of the ship’s crew was aware of or understood this back up method. Had they been thoroughly familiar with the system and its operation, they would have become aware of its partial failure, been able to take action to mitigate against it, and modified their firefighting and control strategies.

Figure 16: Halon manifold relief pipe work

Source: ATSB

Maintenance

The ship’s planned maintenance system (PMS) listed the FFE requiring testing and inspection at regular intervals. Additionally, the PMS incorporated the flag State’s guidelines^[22] for maintenance and inspection of the FFE.

The testing and inspection routines for the fixed fire-extinguishing system (Halon system) were scheduled at weekly, monthly, annually, biennial, 5-yearly and 10-yearly intervals. Therefore, the failed components identified by investigators should have been tested and inspected numerous times as per the PMS-scheduled routines. Had such regular planned maintenance been carried out, the system would probably have been operational at the time of the fire.

The PMS required frequent checks of all components – from the bottle pressures and pressure gauges, to the condition of the system pipework and operation of valves. However, no shipboard maintenance records could be located and, according to the crew, these had been destroyed in the fire. However, the ATSB investigators identified service agents’ maintenance stickers in the Halon room. The stickers indicated that the system, including the bottles, had been checked 4 months before the fire. However, other stickers indicated that the maintenance of the pilot CO2 bottle in the FCR was 2 years overdue and inspection of the pilot CO2 bottle in the Halon room was 9 years overdue.

While it is unknown if the crewmembers had completed the required tests and inspections on the FFE, the multiple system failures and condition of some system components suggested that regular and effective maintenance attention had not been carried out.

Shore response

The Department of Fire and Emergency Services (DFES) is the hazard management agency (HMA) for any marine transport emergency (MTE) involving a fire that occurs in WA waters. As the HMA, it has overall responsibility for the control and coordination of the response, which is exercised through the incident controller (IC). The IC is in command of the overall operations at the incident scene.

In Port Hedland’s port limits, PPA is the controlling agency for an MTE, and its role is to assist the HMA with marine expertise and response coordination. The role of BHP Billiton, the maritime export facility owner, is to initially provide the IC.

Incident controller

After Marigold’s master reported the fire to Port Hedland’s SCT, the duty VTSO initiated the emergency call out procedure as per the PPA’s ERP.

In response, BHP Billiton mobilised its duty response team. The senior ESO arrived on the scene first and assumed the role of IC. Therefore, BHP Billiton was the lead combat agency at this time (in accordance with the ERP). Shortly after, two South Hedland VFRS firefighters arrived at the berth, and the senior firefighter relieved the ESO as IC. Subsequently, when the ESS arrived at the berth, he received a handover from the senior firefighter before assuming the IC role.

At that time, the DFES acting area officer (AO) was travelling from Karratha to Port Hedland. He contacted the SCT and advised that as IC, he was directing that no one enter the ship’s engine room. Shortly after, a VFRS firefighter took a phone call from the AO, which he transferred to the IC at the scene. The AO then issued instructions to seal the engine room and monitor temperatures.

When the AO arrived on the scene some time later, the IC briefed him. However, the AO did not take control of the incident.

At about 1800, the ESOs reported that the fire appeared to be smouldering and temperatures were reducing. The ESS, ESOs and others then expected to make an entry into the engine room. However, the AO advised the ESS (still in the IC role) and PPA that he would not allow entry to the engine room until three consecutive measured temperature reductions were recorded.

It was not until 2004 on 13 July that the AO took over as IC from the ESS.

Recounting their experiences after the emergency, the representatives of each agency noted that command and control arrangements had been confused in the initial hours. Significant matters pointed out included the following:

• PPA assumed that the DFES AO was the IC after he issued instructions to seal the engine room and monitor temperatures while still en route to Port Hedland.
• BHP Billiton’s ESS briefed the AO when he arrived at the scene. However, instead of assuming the IC role, he indicated that DFES could take control of the incident at any point in time. Yet the AO continued issuing orders while the ESS was still in the IC role.
• DFES felt that in the initial stages there appeared to be two ICs (from PPA and BHP Billiton).
• At 2004, when the AO officially assumed the IC role, he did not receive a formal handover from the ESS.
• PPA did not declare an ‘incident level’ for the emergency, as required by its ERP.

Despite the inter-agency agreements, arrangements and emergency plans, it was evident that there were misunderstandings with respect to the role of each agency in the early stages of the incident. Their emergency plans did not define trigger points for the transfer of control or include adequate instructions on formal hand over of responsibilities during incident response. Further, there were inconsistencies between individual emergency plans with respect to a multi-agency response, and command and control arrangements.

First responders checklist

The DFES provided its first response fire services in regional ports with a ‘ship firefighting cache’. The cache contained the marine fire emergency response guide (MFERG), which included the ‘Ship fire response checklist’. The checklist provided guidance for establishing firefighting strategies and recording incident information.

In Port Hedland, the ship firefighting cache was located at the local fire station. However, the designated multi-agency first responders (BHP Billiton and South Hedland VFRS) did not have a copy of the MFERG.

The ship firefighting cache was stowed with the VFS firefighter’s machinery and equipment. The large size of the cache resulted in the VFS firefighter having difficulties loading it into the Port Hedland fire appliance, which delayed his arrival at the berth. Further, once he had arrived with the cache, no one used the MFERG.

The ESS used BHP Billiton’s ‘Tactical response plan for shipboard fires’. The content of the checklist/s in this plan was different to that of the MFERG checklist. Therefore, each party would have been unfamiliar with the others’ process, particularly if used to handover the IC role.

It would have been prudent for all agencies to be completely familiar with the MFERG checklist. Each agency would then have been able to work with the same guidance to manage the MTE.

On 13 July, the ‘Ship fire response checklist’ could have been started by the first IC and then accurately maintained by each successive IC. This would have assisted in removing ambiguities and confusion throughout the emergency response and enabled appropriate IC handovers.

International shore connection

The DFES directive for land-based marine firefighting required a connection to the international shore coupling^[23] to be established as soon as possible. Connection of the land-based fire hose to a ship’s fire hydrant allows a water supply to its fire main. Each ship firefighting cache required an international shore connection.

Further, SOLAS regulations^[24] require all ships of 500 gross tons and over to have an international shore connection on board. Therefore, a connection should always be available.

When the first responders arrived at the berth, ESO’s ran fire hoses from a shore fire hydrant. A South Hedland VFRS firefighter noted that an international shore connection was not connected to the shipboard end of a fire hose. However, ESO’s and firefighters continued connecting lengths of hose, which were then passed up onto the ship. The hose was connected to a ‘Y’ branch that fed two hoses, one of which the ESO’s used to enter the steering gear room. The insufficient length of the hose limited their access and movement.

Most regional areas in WA, including Port Hedland, have low mains water pressure. Therefore, had the shore responders utilised an international shore connection, a relay pump system could have been provided using the fire engines in attendance. The shore hoses would then have pressurised the ships fire main and hydrants (and hoses) in locations near the fire could have been utilised. This would have increased the firefighting capacity and the options for a defensive or offensive strategy.

Firefighting tugs

The PPA ERP provides the following guidance for tug deployment to fight a shipboard fire at a berth:

The Harbour Master will deploy firefighting tugs to assist with firefighting and to protect vessels or other interests in the port. The local VFSR officer will be on board a tug directing fire-fighting operations, while the operational control of the tug remains with the tug master.

However, a VFRS officer was not available on 13 July, as both South Hedland VFRS firefighters were assisting the IC on the berth. Meanwhile, the Port Hedland VFS was transporting the ship firefighting cache to the berth. Consequently, when the harbour master mobilised firefighting tugs, there was no DFES firefighter on board a tug to direct firefighting operations.

Firefighting capabilities in Port Hedland

At the time of the fire, the DFES firefighting capability in Port Hedland consisted of volunteer firefighters: one on duty in Port Hedland (VFS) and two in South Hedland (VFRS). Professional firefighters were stationed in Karratha, about 245 km away, and specialised firefighters (ship entry) in Perth, about 1,650 km away.

In the initial stages of the incident response, only the three volunteer firefighters attended the scene. It is evident that this number of available firefighters in the port could not effectively respond in accordance with agreed emergency plans.

Further, the AO declined the ESO’s suggestion to make an entry into the engine room on the basis that that he required three consecutive temperature reductions before allowing entry. However, had this condition been met and entry was possible, the DFES had no MFASC (ship entry) firefighters on scene to make such entry. It was not until about 24 hours after the fire had started that the Perth-based MFASC brigade arrived on the scene.

The lack of professional firefighters in the area restricted firefighting strategies for tackling shipboard fires in Port Hedland. While MFASC firefighters are trained and equipped to enter confined spaces and suppress fires, volunteer firefighters are trained to contain the fire until additional expertise is available. MFASC firefighters are required for offensive attacks, such as may be required if the ships fixed fire suppression system has been exhausted, or to rescue personnel. Without any MFASC firefighters immediately available, the initial strategy by the first responders would be defensive - regardless of the situation or the need for rescue.

Access control

The DFES procedures required the ship’s engine room and the accommodation atmosphere to be tested to determine the level of post-fire toxins and to provide advice regarding PPE requirements.

The tests measured levels of oxygen (O2), hydrogen sulphide (H2S), carbon monoxide (CO), flammable gases (LEL) and volatile organic compounds (VOC).

The photo ionisation detector (PID) required to test VOCs was normally stored in Karratha. However, at the time of the incident, the Karratha-based professional firefighters were not aware that the PID was in Perth for routine maintenance. This delayed the testing, as an operational PID needed to be air freighted from Perth.

At 2035 on 15 July, DFES officers completed the testing. The O2, H2S, CO and LEL levels were at normal and safe levels. However, the VOCs throughout the ship were above the permissible exposure limits.

Consequently, DFES provided the harbour master with the following advice:

• residential decks not suitable for long term exposure (greater than 4 hours)
• respiratory masks to be worn
• disposable overalls to be worn
• gloves to be worn
• maintain a hygiene station with soap and water
• continue mechanical ventilation.

However, during the time from when the fire started and the atmospheric tests were completed, numerous personnel accessed the ship and spaces within it. These personnel had not been provided with any guidance about hazardous areas or PPE requirements. Further, most crewmembers had slept on board overnight – many of them inside the affected accommodation.

The delay in atmospheric testing meant that anyone who was on board during the 53 hours after the fire started had been potentially exposed to unmitigated, hazardous conditions.

__________

20. Compression fittings are a basic style of tube fitting and are made up of three parts to complete a tubing joint: an olive (ferrule), nut and body. The joint is made by inserting the tube down to the tube stop and tightening a nut – creating a seal by conforming the olive to the shape of the radius and taper of the body and nut.
21. SOLAS 1981 Chapter II-2, Regulation 47, Doors in fire resisting divisions.
22. Panama Maritime Authority Merchant Marine Circular MMC-281 ‘Guidelines for maintenance and inspection of the FFE’.
23. An international shore connection consists of a standard flange that is fitted to the ship’s fire main. It allows land based fire services hose to supply the ship’s fire main. The ship’s part of the international shore connection also has a flange. Once the flanges have been bolted together, fire service pumps can supply water to the ship’s fire main.
24. SOLAS 1981 Chapter II-2, Regulation 19

Findings

From the evidence available, the following findings are made with respect to the engine room fire on board Marigold while the ship was loading cargo in Port Hedland, Western Australia on 13 July 2014. These findings should not be read as apportioning blame or liability to any particular organisation or individual.

Safety issues, or system problems, are highlighted in bold to emphasise their importance. A safety issue is an event or condition that increases safety risk and (a) can reasonably be regarded as having the potential to adversely affect the safety of future operations, and (b) is a characteristic of an organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operating environment at a specific point in time

Contributing factors

• At about 1447 on 13 July 2014, a fire started on Marigold’s number 1 diesel generator after a fuel oil pressure gauge compression fitting failed. Pressurised fuel oil escaping from the fitting then ignited after it came in contact with a sufficiently hot surface on the generator.
• The compression fitting that failed had been used to connect a replacement pressure gauge that had a different pipe connection fitting size to the original pressure gauge.
• A number of Marigold’s engine room fire doors were held open by wire and/or rope. The open doors allowed the smoke to spread across the engine room and into the accommodation spaces. [Safety issue]
• The maintenance of the opening/closing arrangements for Marigold’s engine room fire dampers, ventilators and other openings was inadequate. A number of these could not be closed, resulting in the inability to seal the engine room to contain and suppress the fire. [Safety Issue]
• Marigold’s Halon gas fixed fire suppression system for the engine room was not fully operational. The multiple failures of the system at the time of the fire were not consistent with proper maintenance and testing. [Safety Issue]
• Marigold’s shipboard procedures for crew induction, familiarisation, fire drills and safety training were not effectively implemented. As a result, the ship’s senior officers were not sufficiently familiar with the Halon system’s operation. They did not identify its partial failure and did not activate the override function. [Safety Issue]

Other factors that increased risk

• Port Hedland’s emergency response teams did not use the ship’s international shore fire connection. As a result, Marigold’s fire main was not pressurised with water from ashore. [Safety Issue]
• The emergency response plans for a ship fire in Port Hedland did not clearly define transfer of control procedures for successive incident controllers from different organisations or contain standard checklists for their use. [Safety Issue]
• The large size and weight of the ship firefighting cache made it difficult for the duty Port Hedland volunteer firefighter to transport it to the wharf. [Safety Issue]
• Shutting down Marigold’s emergency generator cut power to the ship’s fire pump and systems and reduced the available firefighting resources and capacity.
• Contrary to the ship’s procedures and accepted safe practice, some crew members used the lift to evacuate the engine room after the fire started.
• Suitable atmospheric testing equipment was not available in Port Hedland to ensure safe entry to fire-affected spaces on board Marigold. Access to these areas was not controlled until 53 hours after the fire. [Safety Issue]
• The limited professional firefighting capability in Port Hedland restricted the ability to launch an effective response to the fire on board Marigold. [Safety Issue]

Safety issues and actions

The safety issues identified during this investigation are listed in the Findings and Safety issues and actions sections of this report. The Australian Transport Safety Bureau (ATSB) expects that all safety issues identified by the investigation should be addressed by the relevant organisation(s). In addressing those issues, the ATSB prefers to encourage relevant organisation(s) to proactively initiate safety action, rather than to issue formal safety recommendations or safety advisory notices.

All of the directly involved parties were provided with a draft report and invited to provide submissions. As part of that process, each organisation was asked to communicate what safety actions, if any, they had carried out or were planning to carry out in relation to each safety issue relevant to their organisation.

The initial public version of these safety issues and actions are repeated separately on the ATSB website to facilitate monitoring by interested parties. Where relevant the safety issues and actions will be updated on the ATSB website as information comes to hand.

Fire doors

A number of Marigold’s engine room fire doors were held open by wire and/or rope. The open doors allowed the smoke to spread across the engine room and into the accommodation spaces.

ATSB Safety Issue: MO-2014-008-SI-01

Ventilation closedown

The maintenance of the opening/closing arrangements for Marigold’s engine room fire dampers, ventilators and other openings was inadequate. A number of these could not be closed, resulting in the inability to seal the engine room to contain and suppress the fire.

ATSB Safety Issue: MO-2014-008-SI-02

Fixed fire suppression system

Marigold’s Halon gas fixed fire suppression system for the engine room was not fully operational. The multiple failures of the system at the time of the fire were not consistent with proper maintenance and testing.

ATSB Safety Issue: MO-2014-008-SI-03

ATSB Safety Recommendation: MO-2014-008-SR-035

Halon system

Marigold’s shipboard procedures for crew induction, familiarisation, fire drills and safety training were not effectively implemented. As a result, the ship’s senior officers were not sufficiently familiar with the Halon system’s operation. They did not identify its partial failure and did not activate the override function.

ATSB safety Issue: MO-2014-008-SI-04

International shore connection

Port Hedland’s emergency response teams did not use the ship’s international shore fire connection. As a result, Marigold’s fire main was not pressurised with water from ashore.

ATSB Safety issue: MO-2014-008-SI-05

ATSB Safety Recommendation: MO-2014-008-SR-037

Incident control

The emergency response plans for a ship fire in Port Hedland did not clearly define transfer of control procedures for successive incident controllers from different organisations or contain standard checklists for their use.

ATSB Safety Issue: MO-2014-008-SI-06

ATSB Safety Recommendation: MO-2014-008-SR-040

Access control

Suitable atmospheric testing equipment was not available in Port Hedland to ensure safe entry to fire-affected spaces on board Marigold. Access to these areas was not controlled until 53 hours after the fire.

ATSB Safety issue: MO-2014-008-SI-07

ATSB Safety recommendation: MO-2014-008-SR-041

Professional firefighters in Port Hedland

The limited professional firefighting capability in Port Hedland restricted the ability to launch an effective response to the fire on board Marigold.

ATSB Safety Issue: MO-2014-008-SI-08

Ship firefighting cache

The large size and weight of the ship firefighting cache made it difficult for the duty Port Hedland volunteer firefighter to transport it to the wharf.

ATSB Safety issue: MO-2014-008-SI-09

ATSB Safety Recommendation: MO-2014-008-SR-043

Sources and submissions

Sources of information

The sources of information during the investigation included:

• Marigold’s master and directly involved crewmembers
• Port Hedland’s harbour master and shipping superintendent
• Port Hedland Pilots
• BHB Billiton marine manager and emergency services supervisors
• The Korean Register of Shipping.

References

Government of Western Australia, Department of Transport, Western Australia, Port Authorities Act 1999 (WA), WADOT, Perth. Available from

Government of Western Australia, Department of Fire and Emergency Services, 2013, Marine Fire Emergency Response Guide, WADFES, Perth.

Government of Western Australia, Department of Fire and Emergency Services, 2013, Directive 3.18 Land Based Marine Firefighting, WADFES, Perth.

Government of Western Australia, Department of Fire and Emergency Services, 2014, Marine Firefighting – Learners Manual, WADFES, Perth.

Government of Western Australia, Department of Transport, Western Australia, 2011, State Emergency Management Plan for Marine Transport Emergency (WESTPLAN – MTE), WADOT, Perth. Available fro:

• Government of Western Australia, Department of Fire and Emergency Services, 2013, State emergency management plan for fire (WESTPLAN – Fire), WADFES, Perth. Available from
• International Maritime Organisation, 2015, The International Convention for the Safety of Life at Sea (SOLAS) 1974, as amended, IMO, London.
• Port Hedland Port Authority, Emergency Response Procedure, Pilbara Port Authority. Available from
• BHP Billiton Iron Ore, 2014, Security & Emergency Management, Emergency Management Plan, Part 1 Version 2.0, BHP Billiton.
• BHP Billiton Iron Ore, 2014, Health & Safety, Crisis and Emergency Management Version 2.0, BHP Billiton.

Submissions

Under Part 4, Division 2 (Investigation Reports), Section 26 of the Transport Safety Investigation Act 2003 (the Act), the Australian Transport Safety Bureau (ATSB) may provide a draft report, on a confidential basis, to any person whom the ATSB considers appropriate. Section 26 (1) (a) of the Act allows a person receiving a draft report to make submissions to the ATSB about the draft report.

A draft of this report was provided to:

• Marigold’s master and directly involved crewmembers
• the Korea Leading Company of Ship Management
• Port Hedland’s harbour master and shipping superintendent
• Port Hedland Pilots
• BHB Billiton marine manager and emergency services supervisors
• Department Fire and Emergency Services (DFES) Superintendent
• Australian Maritime Safety Authority.
• Submissions were received from:
• the Korea Leading Company of Ship Management
• Port Hedland’s harbour master and shipping superintendent
• BHB Billiton marine manager
• Australian Maritime Safety Authority.

The submissions were reviewed and where considered appropriate, the text of the report was amended accordingly.

Purpose of safety investigations The objective of a safety investigation is to enhance transport safety. This is done through: identifying safety issues and facilitating safety action to address those issues providing information about occurrences and their associated safety factors to facilitate learning within the transport industry. It is not a function of the ATSB to apportion blame or provide a means for determining liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action. Terminology An explanation of terminology used in ATSB investigation reports is available here. This includes terms such as occurrence, contributing factor, other factor that increased risk, and safety issue. Publishing information  Released in accordance with section 25 of the Transport Safety Investigation Act 2003 Published by: Australian Transport Safety Bureau © Commonwealth of Australia 2016 Ownership of intellectual property rights in this publication Unless otherwise noted, copyright (and any other intellectual property rights, if any) in this report publication is owned by the Commonwealth of Australia. Creative Commons licence With the exception of the Coat of Arms, ATSB logo, and photos and graphics in which a third party holds copyright, this publication is licensed under a Creative Commons Attribution 3.0 Australia licence. Creative Commons Attribution 3.0 Australia Licence is a standard form licence agreement that allows you to copy, distribute, transmit and adapt this publication provided that you attribute the work. The ATSB’s preference is that you attribute this publication (and any material sourced from it) using the following wording: Source: Australian Transport Safety Bureau Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you wish to use their material, you will need to contact them directly.

What happened

On 13 July 2014, the pilot of a Cessna 172 aircraft, registered VH-EEC, conducted a private flight from The Lily to Narrikup aeroplane landing areas (ALA), Western Australia, with two passengers on board.

At about 1320 Western Standard Time, the pilot broadcast an inbound call when about 10 NM north-east of Narrikup at about 6,500 ft above mean sea level (AMSL). The pilot elected to conduct an approach to runway 06 and overflew the runway at about 1,900 ft AMSL. He observed the windsock which did not indicate any significant crosswind. The aircraft then descended to circuit height and joined on the crosswind leg for runway 06.

When established on final for runway 06, the pilot reported that he had selected two stages of flap and had the aircraft stabilised at about 65 kt. When about 50 ft above ground level, the pilot reported that the aircraft encountered a wind gust which carried the aircraft about 30 m to the right. The pilot moved the aileron controls into wind and applied full power to commence a go-around; however, the aircraft’s right wing collided with trees on the right side of the landing area. The pilot reported that the right wing may have stalled as he applied full right aileron. The aircraft fell to the ground resulting in substantial damage.

This incident highlights the importance of being ready to conduct an early go-around when a pilot is not completely satisfied that a safe landing can be made.

Aviation Short Investigations Bulletin - Issue 34

What happened

On 12 July 2014, a pilot was undergoing training for mustering approval by a supervising pilot in a Robinson R22 helicopter, registered VH-ZZM. After completing about 7 hours of mustering, the helicopter was returning to a homestead near Dingo, Queensland, when about 1,000 ft above ground level (AGL) the supervising pilot instructed the pilot to conduct a practice autorotation turning through 180°, which the pilot completed, increasing power when at about 5 ft AGL.

 During the subsequent climb, when at about 450 ft AGL, the supervising pilot took control of the helicopter and initiated a second autorotation. The supervising pilot initially observed the airspeed at about 65 kt, the rotor rpm in the green arc and the autorotation ‘looking good’, and assumed at this stage that he had handed control of the helicopter to the other pilot. At about 100 ft AGL, the pilot detected the rotor rpm decaying and a rapid rate of descent, but still assumed that the supervising pilot had control of the helicopter. When at about 20-40 ft AGL, the supervising pilot observed the vertical speed increasing and the rotor rpm decreasing and rapidly lowered the collective and increased the throttle. Just prior to the helicopter contacting the ground, the supervising pilot flared then levelled the helicopter and raised the collective.

The helicopter landed hard, bounced once and rotated through about 180° before coming to rest. The pilot sustained serious injuries and the supervising pilot minor injuries. The helicopter was substantially damaged.

This incident highlights the importance of good communication between a flight instructor and their student and the use of handover/takeover techniques to clarify who has control of the aircraft at any time.

Aviation Short Investigations Bulletin - Issue 34

Safety 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

At 1300^[1] on 5 July 2014, the 185 m long container ship, Kota Wajar (cover), anchored off the Port of Brisbane, Queensland, after a sea passage from Tauranga, New Zealand. The ship was scheduled to embark a harbour pilot on the following day to berth in Brisbane.

At that time, the 44 foot (13.4 m) yacht, Blazing Keel (Figure 1) was making its way east across Moreton Bay (Figure 2). The yacht, a single-masted cutter equipped with a diesel engine, had left Newport Marina in the Redcliffe area about 2 hours earlier. The yacht’s skipper (and owner) and his wife were on board. They had planned to dive on Curtin Artificial Reef off Moreton Island on the following day (Sunday) as they had many times in the past.

Figure 1: Blazing Keel

Source: Queensland Police Service

Figure 2: Moreton Bay, Port of Brisbane

Source: Port of Brisbane Corporation (annotated by ATSB)

 At about 1700, the yacht arrived near the diving destination north of Cowan Cowan Point, where it was then anchored. Weather conditions were good with a light (5 knots)^[2] northerly wind, partly cloudy sky and clear visibility. By 1900, the skipper and his wife had turned in for the night.

At about 0030 on 6 July, the skipper awoke and went out on Blazing Keel’s deck. The wind was now from the west-southwest at about 10 knots. Over the next hour, the skipper felt that the sea was becoming rougher in the strengthening wind. By 0130, the wind was gusting to 14 knots.

Meanwhile Kota Wajar’s crew were weighing anchor in preparation to embark its scheduled pilot. The anchor was aweigh at 0200 and, at 0224, the pilot boarded the ship from a pilot boat.

At 0226, the pilot arrived on the ship’s navigation bridge, exchanged information with the master and took over the conduct (con) of the ship. He also provided the master the standard passage plan for the 48 mile^[3] pilotage to the ship’s berth at Fisherman Islands, near the entrance to the Brisbane River. The second mate (the officer of the watch) and the duty seaman, who was hand steering the ship, were the other members of the bridge team. The fourth mate, the junior-most deck officer on board, who had been on the bridge since 0130 in preparation for pilot boarding, then left the bridge to rest.

By 0230, Kota Wajar was on a heading^[4] of 200° towards the entrance of the shipping channel. The ship’s speed^[5] was 11 knots and increasing. At 0250, it passed the NW Fairway beacon and entered the North West Channel (Figure 2).

At 0315, the ship passed NW6 beacon making good 17 knots (as per its passage plan for the Moreton Bay transit). The pilotage was progressing as planned and there were no other ships in the channel nearby. At about this time, the master left the bridge.

Meanwhile, Blazing Keel’s anchor chain started to pay out in the now westerly, 15 knot wind gusts and increasingly rough seas. The skipper decided to weigh anchor and return to Newport Marina under power using the yacht’s engine rather than setting its sails in the windy conditions.

At about 0330, the yacht’s anchor was aweigh and the skipper started its engine. He turned on the yacht’s navigation lights, checked that they were lit and set a southerly course towards Cowan Cowan Point. The yacht made good about 4.5 knots and the skipper and his wife remained in its cabin from where they could look out through the cabin windows.

At 0400, Kota Wajar was transiting the Main Channel (Figure 3) when the routine change of bridge watch took place. The chief mate took over the watch from the second mate. The fourth mate had returned to the bridge to gain watchkeeping experience and assist the chief mate. The helmsman (duty seaman) had also changed.

The pilot was using visual cues, the ship’s radar and his portable pilotage unit (PPU) to conduct the pilotage. He stood on the starboard side of the bridge near the radar and his PPU, and had a clear view out of the bridge front windows. When a course alteration was needed, he moved to a conning position near the centreline gyro compass repeater. The chief mate stood near the radar and, from to time, checked the ship’s position being plotted on the navigational chart by the fourth mate. The fourth mate was also assisting with the keeping of a visual lookout.

The ship was on a heading of 162° after an uneventful passage through the North West and Spitfire Channels. It was a dark night (the moon had set before midnight) and the visibility remained good. The nearest ship, the dredger Charles Darwin, about 8 miles away, was dredging in the East Channel.

By 0400, Kota Wajar’s radar was consistently displaying Blazing Keel’s radar echo. The yacht was about 30 degrees on the ship’s port bow and 4.5 miles away. No one on the bridge had detected the yacht visually or by radar.

By 0410, the distance between Kota Wajar and Blazing Keel had closed to 2.2 miles. The ship’s heading was now 139° with Cowan Cowan Point lighthouse directly ahead, M6 beacon to port and the yacht fine on its port bow. The bridge team remained unaware of the approaching yacht.

At 0413, Blazing Keel crossed 1.6 miles ahead of the ship (that is, from the ship’s port bow to its starboard bow). The skipper and his wife did not see any ships in the channel and he decided to cross it near M7 beacon. By 0415, the yacht was on a south-westerly course at 4.5 knots.

Meanwhile, Kota Wajar arrived off M5 beacon and, at 0415, its course was altered. By 0416, the ship was on a heading of 162° towards M7 beacon. The brightly lit Charles Darwin was conspicuous about 5 miles away, 22 degrees on the ship’s starboard bow. Blazing Keel was once again on the ship’s port bow (12 degrees) and about 0.8 of a mile away. The ship and yacht were on a collision course. No one on board either vessel was aware of the close-quarters situation.

Figure 3: Section of navigational chart Aus 236 showing the tracks of both vessels

Source: Australian Hydrographic Service (annotated by ATSB using electronically recorded data)

The distance between Kota Wajar and Blazing Keel rapidly closed as they approached M7 beacon. At 0418½, when the ship was near the beacon, the pilot began conning to alter course in order to follow the channel on a 185° heading. By 0419, the ship’s heading was 177° with the undetected yacht less than 100 m away on its port bow and closing.

Blazing Keel’s skipper and his wife had not seen the rapidly approaching ship.

At 0419½, as Kota Wajarwas steadied on a heading of 185° in a position immediately east of M7 beacon, it collided with Blazing Keel. The port side of the ship’s bulbous bow first made contact with the starboard side of the yacht, which was on a heading of about 225°.

Blazing Keel’s skipper only realised what had happened when he saw the ship’s dark hull illuminated by the yacht’s aft cabin and galley lights. He quickly put the rudder over to port and the engine throttle to full in an attempt to get clear of the ship. The yacht remained alongside the ship for about 30 seconds, bumping and scraping against its hull, until the curve of the ship’s stern had passed.

Once the yacht was astern of Kota Wajar, the skipper saw bright lights at its stern but could not read the ship’s name. He reduced the yacht’s speed to about 4 knots, checked that its steering was working and confirmed that he and his wife had not been injured. He then asked his wife to check the yacht for damage and leaks.

No one on board Kota Wajar saw or heard the collision or become aware of the yacht nearby. As the ship was steadied on a heading of 185°, the bright lights of Charles Darwin were now fine on the starboard bow (bearing 189°). The dredger was returning to port with an expected entry time earlier than the ship.

The ship continued its passage along the channel as planned.

By 0421, Blazing Keel’s skipper had set a southerly course along the channel while his wife was checking for damage. The skipper attempted to call Redcliffe coastguard using a handheld VHF radio but got no response. He then broadcast an urgency message to all stations on channel 16 and again received no response.

At about 0425, the skipper’s wife reported damage on Blazing Keel’s starboard side, including its mast and rigging, but no water ingress. The skipper shone a torch out on the rigging and noted significant damage. He then checked the yacht’s bilges and found them dry. Satisfied that the hull was watertight, he decided to resume the passage to the marina. By 0427, he had set a south-westerly course.

Shortly after 0500, Kota Wajar’s master returned to the bridge. At about 0518, the ship’s speed was reduced as it approached the port. By 0612, the ship had been secured alongside its berth and the pilot left shortly afterwards.

At 0630, Blazing Keel’s skipper established radio contact with Redcliffe coastguard and reported the collision. By 0730, the yacht had berthed in Newport Marina and the skipper then completed a thorough inspection of the yacht. There was extensive hull damage on its starboard side, both above and below the waterline, and the ship’s red boot-topping paint marks were clearly visible. The handrails, rigging and a number of mast stays and spreaders were damaged.

Shortly thereafter, the skipper and his wife attended the local water police station to provide their statements to the police. The time, location and other details of the collision were then passed on by the police to the port authority and others to follow up with involved parties.

At about 0800, Kota Wajar’s pilot was advised by the pilot office that the ship had collided with a yacht at about 0430 off Cowan Cowan Point. The ship’s master was also advised of the collision. The yacht’s blue and white paint marks were clearly visible near the waterline on the ship’s bulbous bow and along the port side in a number of places.

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1. All times referred to in this report are local time, Coordinated Universal Time (UTC) + 10 hours.
2. One knot, or one nautical mile per hour, equals 1.852 kilometres per hour.
3. A nautical mile of 1,852 m.
4. All ship’s headings in this report are in degrees by gyro compass with negligible error.
5. All speeds referred to in this report are ‘made good/over the ground’.

Context

Kota Wajar

The fully cellular, 1,550 TEU^[6] Kota Wajarwas fitted with navigational equipment required for a ship of its size under SOLAS.^[7] The two Kelvin Hughes radars, an x-band MK 5 and an s-band MK 7, had automatic radar plotting aid (ARPA) and other target tracking functions. Both radars also had data input from the ship’s automatic identification system (AIS) transceiver and global positioning system (GPS) receiver unit.

At the time of the collision, Kota Wajar was managed by Pacific International Lines, Singapore (PIL) which operates a large fleet of container ships. The container ship was on a regular service between ports in Asia and Australia and had called in Brisbane about once a month during the last 6 months. Its crew of 22 comprised nationals of China, Ghana, India, Indonesia, Myanmar, Poland and Sri Lanka.

The master was from Poland and held a Polish master’s certificate of competency. He had been at sea for 32 years of which the last 12 had been as master. He had been sailing on PIL container ships for 18 years. He had joined Kota Wajar about 5 months before the incident.

The chief mate was from Myanmar, where his master’s certificate of competency was issued, and had been at sea for 10 years. He had sailed as chief mate for 5 years, the last 1 year of which had been on PIL container ships. He had been on board Kota Wajar for about 2 months.

The Chinese fourth mate held a Class 3 certificate of competency for a watch keeping officer. He started his seagoing career with PIL about 14 months before the incident. He had been on board Kota Wajar for about 2 months and it was his first assignment as fourth mate.

The duty seaman at the time of collision was Indonesian. He had been at sea for 12 years, all of which had been on board PIL container ships. He had been on board Kota Wajar for 9 months.

Blazing Keel

Blazing Keel, a single-masted cutter with a steel hull, was registered in Queensland at the time of the collision. The yacht was equipped with an 85 horsepower diesel engine. Its principal means of navigation was a GME G-Combo G142CFD electronic chart plotter (incorporating a GPS receiver) and a compass. The yacht was fitted with a Koden MD-3000 radar but it had not been operational for about 18 months.^[8]

Blazing Keel’s skipper and his wife were residents of Brisbane. Both had held a Queensland recreational marine driver licence (RMDL) for about 10 years. They had also held powerboat licences (to operate a ski boat) for about 25 years. In 2008, the skipper had attended a training course to obtain a skipper’s licence for inshore waters.

The skipper had owned Blazing Keel for about 3 years. His experience of sailing a yacht in Moreton Bay was limited to this period. The experience of his wife, who routinely sailed with him, was similar.

Navigation lights

The International Regulations for the Prevention of Collisions at Sea, 1972, as amended (COLREGS) require all vessels to exhibit specific lights (commonly known as navigation lights) from sunset to sunrise.

The navigation lights of a power-driven vessel underway consist of a masthead light^[9] forward, a second masthead light abaft of, and higher than the forward one (mandatory for vessels 50 m or more in length), sidelights^[10] and a sternlight.^[11] Kota Wajar was required to exhibit all of these lights. At the time of the collision, the working lights along the ship’s cargo hold hatch coamings and flood lights at its stern were also on.

When the collision occurred,Blazing Keel was being powered by its engine and its sails were not set. As a power-driven vessel that was not less than 12 m in length, it was required to exhibit a masthead light, sidelights and a sternlight. The yacht was fitted with a masthead light, sidelights near its bow and a sternlight aft. In addition to these lights, the skipper stated that he had turned on the ‘tricolour’ light on the mast. He was referring to the combined lantern that is permitted for a sailing vessel of less than 20 m in length.^[12]

Port of Brisbane

The Port of Brisbane is Queensland’s largest multi-cargo port and one of Australia’s fastest growing container ports. At present, more than 2,600 ships call in Brisbane each year. The port is approached through Moreton Bay and the container terminal is located at Fisherman Islands at the mouth of the Brisbane River.

The shipping channels in Moreton Bay are dredged to maintain depths and are marked by beacons and buoys (fitted with lights). Frequent changes to the shoals, channels and navigation marks (aids) make local knowledge essential for safe navigation. Ships of 50 m or more in length (unless exempted) are required to take a pilot.

Pilotage is provided by Brisbane Marine Pilots (BMP) under the regulatory regime of Maritime Safety Queensland. Ships can transit Moreton Bay at their sea speed (and often do) if the master and pilot agree after considering the prevailing conditions, under-keel clearance, scheduling and traffic. Traffic in the bay regularly includes fishing and recreational craft from a number of marinas and small boat harbours the area. Moreton Island and the waters of its western shores are popular recreational areas.

Kota Wajar’s pilot first went to sea in 1980. His seagoing career as a deck officer included experience as a ship’s master. He began piloting in the late 1990s and, in 2003, joined BMP. At the time of the incident, he had held an unrestricted pilot’s licence for Brisbane for about 9 years.

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6. Twenty-foot Equivalent Unit, a standard shipping container. The nominal size of ships in TEU refers to the number of standard containers that it can carry.
7. The International Convention for the Safety of Life at Sea, 1974, as amended.
8. The yacht was not required by regulations to be equipped with radar.
9. COLREGS Rule 21 (a) states: ‘Masthead light means a white light placed over the fore and aft centreline of the vessel and showing an unbroken light over an arc of the horizon of 225º and so fixed as to show the light from right ahead to 22.5º abaft the beam on either side of the vessel’.
10. COLREGS Rule 21 (b) states: ‘Sidelights means a green light on the starboard side and a red light on its port side each showing an unbroken light over an arc of the horizon of 112.5º and so fixed as to show the light from right ahead to 22.5º abaft the beam on its respective side. In a vessel of less than 20 m in length, the sidelights may be combined in one lantern carried on the fore and aft centreline of the vessel’.
11. COLREGS Rule 21 (c) states: ‘Sternlight means a white light placed as nearly as practicable at the stern showing an unbroken light over an arc of the horizon of 135º and so fixed as to show the light 67.5º from right aft on each side of the vessel’.
12. Under COLREGS Rule 25 (b), a sailing vessel of less than 20 metres in length is permitted to combine the prescribed sidelights and sternlight in one lantern carried at or near the top of the mast where it can best be seen.

Safety analysis

The collision

At 0419½ 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, powered by its engine, was crossing the channel in a southwest direction. The yacht suffered extensive damage but maintained its watertight integrity. The two persons on board were not injured and the yacht safely returned to its marina.

No one on board either vessel saw or otherwise detected the other before the collision.

Keeping a lookout

The COLREGS provide internationally agreed rules and measures to prevent collisions at sea. In general, the regulations apply to all vessels and in all waters. Both Kota Wajar and Blazing Keel had to comply with these regulations while navigating Moreton Bay. As the vessels did not sight each other, the matter of applying rules for taking action to avoid collision did not arise. The key requirement to keep a lookout, however, did apply and was a focus of the ATSB investigation.

With respect to keeping a lookout, COLREGS Rule 5 - Look-out, states:

Every vessel shall at all times maintain a proper look-out by sight and hearing as well as by all available means appropriate in the prevailing circumstances and conditions so as to make a full appraisal of the situation and of the risk of collision.

Rule 5 clearly states the purpose of maintaining a lookout and summarises how a lookout should be kept. Effective compliance with the rule relies on a complete and thorough understanding of the COLREGS to ensure that all relevant matters are taken into account. This understanding should be a core competency for those in charge of a navigational watch on ships – something their seagoing qualifications aim to ensure. Similarly, qualifications to operate small recreational craft, including yachts, aim to ensure a sound understanding of the COLREGS to prevent collisions.

An all-round lookout by sight and hearing (inside and outside the bridge) is necessary at all times. Other available means to maintain and enhance keeping a lookout usually include radar, AIS and traffic information from other sources, such as radio broadcasts and ship to ship calls. An effective lookout can ensure the early detection of targets, making possible a full and timely appraisal of the situation and of the risk of collision.

The prevailing circumstances and conditions include the factors that should be considered to keep an effective lookout. Many of these factors are identifiable within the COLREGS; for example Rule 6 - Safe speed, lists several factors that are also relevant to keeping a lookout. Other matters that should be taken into account rely on the practice of good seamanship and an appropriate level of nautical knowledge. Factors relevant to keeping an effective lookout include the:

• state of visibility (and using radar to better assess it when restricted by fog, rain or other cause)
• time of day (day, night or twilight)
• background lights (shore lights or back scatter from own lights)
• expected traffic in the area (open sea, coastal passage, port or harbour)
• traffic density, including concentrations of fishing and other vessels, including small craft
• manoeuvrability of the vessel (including stopping distance and turning ability) and its draught
• state of the wind, sea and current, and the proximity of hazards such as shoals and reefs
• characteristics, efficiency and limitations of radar (including its range and any interference)
• type, capability and limitations of the AIS unit (and features of other vessels’ AIS units)
• available local knowledge and information (sailing directions, pilot and other sources)
• traffic information via radio (ship to ship calls, all ship broadcasts and schedules).

It is worth noting here that a number of the factors listed above are interrelated. For example, radar significantly enhances keeping a lookout, particularly when visibility is restricted by fog, rain or other conditions, and during darkness. Equally, the lack of radar as an available means to keep a lookout on some small vessels needs to be taken into account.

The COLREGS are supported by a number of other requirements and guidelines for mariners. The STCW Code^[13] provides mandatory watchkeeping standards applicable to ‘seagoing ships’, which includes all commercial vessels in domestic or international trade but not recreational craft. The Code requires that a proper lookout is maintained at all times in compliance with Rule 5 of the COLREGS, and comprehensively covers the subject, including the factors discussed above.^[14]

The Code requires that the lookout be able to give full attention to lookout duties and not be assigned or undertake any duties which could interfere with that task. It clarifies that the duties of a lookout and helmsperson on a ship are separate. The Code permits the officer of the watch (OOW) to be the sole lookout in daylight (in good conditions) which implies that another person should be posted as a lookout in darkness. It also states that the master and the OOW, when arranging lookout duty for the hours of darkness, shall have due regard to the bridge equipment and navigation aids available, their limitations, procedures and safeguards implemented.

The Bridge Procedures Guide^[15] brings together the good practice of seafarers with the aim of improving navigational safety and protecting the environment. The publication is acknowledged as the principal industry guidance on the subject and is widely used internationally to support shipboard safety management systems (SMS). It refers to both the COLREGS and the STCW Code and covers all the relevant subjects, including keeping a lookout. The guide is consistent with the requirements of both in terms of what constitutes a proper lookout and the factors to be considered, including restrictions with respect to a sole lookout.

In essence, keeping a lookout in accordance with the COLREGS is mandatory, and fundamental to preventing collisions. The STCW Code provides watchkeeping standards for seagoing ships, including keeping a proper lookout. In addition to other available means of keeping watch, posting a dedicated visual lookout (that is, by sight) during the hours of darkness, in restricted visibility and when warranted by other circumstances or conditions, is necessary.

Kota Wajar’s lookout

Kota Wajar’s SMS procedures^[16] quoted extensively from the COLREGS and the STCW Code with respect to bridge watchkeeping and maintaining a lookout. The procedures were consistent with the Code with regard to the OOW being the sole lookout in daylight. The standard watchkeeping arrangement included a seaman as the dedicated lookout on each navigational watch. It was clearly stated that ‘the duties of the person on lookout and helmsman were separate and the helmsman should not be considered the person on lookout while steering’.^[17]

The shipboard procedures required the OOW to comply with the COLREGS at all times, including ensuring that a good lookout was maintained. Detailed guidance on the proper use of radar was included. The OOW was required to ‘give watchkeeping personnel all appropriate instructions and information necessary for maintaining a safe watch, including a proper lookout’.^[18] This instruction, when appropriately applied, should result in the dedicated visual lookout being given relevant information, particularly in relation to checking for targets detected by radar or AIS but not yet sighted.

Events and conditions on 6 July 2014

At the time of the collision, Kota Wajar’s bridge team comprised the pilot, chief mate, helmsman and the fourth mate, whose main task was to assist the chief mate. As the OOW, the chief mate was responsible for ensuring that a proper lookout was kept in the prevailing circumstances and conditions. The ship was navigating the approaches to the Port of Brisbane during the hours of darkness under the conduct of a pilot. Those conditions warranted posting a dedicated visual lookout and using other available means to maintain a lookout, including radar and AIS.

In this instance however, no one was assigned the duties of a dedicated visual lookout. The pilot and the chief mate were stationed just aft of the bridge front windows near the x-band radar. The s-band radar inside the chartroom was mainly used for position fixing by the fourth mate. The helmsman was steering the ship as per the pilot’s helm and course (heading) orders.

The x-band radar’s main display was set to its north-up, relative motion mode on a 6 mile range scale (Figure 4). The display was set up to show the planned tracks and track limits (in red). The ‘trail’ function was set to indicate the true motion of targets over the past 10 minutes (so moving targets left trails on the display). Trails make a target more conspicuous and distinguish it from sea clutter. The electronic bearing line (EBL) and variable range marker (VRM) were not switched on. The cursor had been placed near the edge of the display on a 099° bearing.

Figure 4: Kota Wajar’s x-band radar’s main display at 0400 on 6 July 2014

Source: Kota Wajar’s voyage data recorder (VDR) with ATSB annotations

Over a 5 minute period around 0400 on 6 July, the second mate handed over the watch to the chief mate. The duty helmsman had changed some time earlier. Between 0357 and 0358, Kota Wajar’s course was altered from 109° to 162° and its position at 0358 was plotted on the chart. By 0400, about 20 minutes before the collision, Blazing Keel’s radar echo was consistently appearing on the x-band radar’s display, about 30 degrees on the port bow at a range of 4.5 miles. None of the three mates or the pilot saw the yacht’s echo or, if they did, paid any attention to it.

Between 0404 and 0405, after the second mate had left the bridge, the ship’s course was altered from 162° to 139°. Its position at 0405 was plotted on the chart by the fourth mate. On its 139° heading, the flashing white light of Cowan Cowan Point lighthouse was nearly ahead. The chief mate remained near the x-band radar, from where he could monitor, amongst other things, the pilot’s helm orders and the ship’s progress along the planned track.

By 0410, Blazing Keel was fine on the ship’s port bow and 2.2 miles away (Figure 5). At 0413, the yacht was right ahead of Kota Wajar, crossing to its starboard bow. Shortly before 0415, the pilot began conning the ship to its next course of 162°. As the ship’s heading changed to starboard, the yacht was once again on its port bow. At 0415, the yacht was 1.1 miles away, fine on the port bow (Figure 6). Its radar echo and trail remained readily discernible, distinct from sea clutter.

Figure 5: Section of radar display at 0410

Source: Kota Wajar’s VDR (annotated by ATSB)

 Figure 6: Section of radar display at 0415

Source: Kota Wajar’s VDR (annotated by ATSB)

Rule 22 of the COLREGS - Visibility of lights, specifies the minimum visibility ranges for a vessel’s navigation lights, depending on its length. Blazing Keel’s masthead light was required to be visible at least 3 miles off, and its sidelights and sternlight at least 2 miles off. Therefore, by 0410, when the yacht was about 2 miles off, its navigation lights should have been visible from Kota Wajar’s bridge. By 0415, when the yacht was about 1 mile off, its lights should have been readily visible.

However, no one on the ship’s bridge said that they saw the yacht’s lights. By 0416, the pilot had ordered the helmsman to steady the ship on a 162° heading. The fourth mate had plotted the position at 0412 and remained occupied with his position fixing tasks. The chief mate remained near the x-band radar. Information recorded by the ship’s voyage data recorder (VDR) indicates that the radar’s EBL, VRM, cursor and its ARPA function were not used in the time leading up to the collision. This suggests that the radar was not actively used to monitor any detected targets.

As its distance closed, Blazing Keel’s echo continued to appear on the x-band radar. At 0418, it was 0.3 of a mile off, fine on the ship’s port bow with its bearing closing. Shortly afterwards, the pilot began conning the ship to its next course of 185°. At 0419½, just as the ship was steadied on a 185° heading, it collided with the yacht. No one on the bridge saw anything to suggest that a collision had occurred. The bridge wing doors were open but nothing was heard.

Why Blazing Keel went undetected

While the chief mate and the pilot had opportunities to sight the yacht out of the bridge windows or see its echo on the x-band radar, they did not. From the ATSB’s analysis, the main reasons and factors why they did not detect the yacht (some applicable to other bridge team members) were:

• a dedicated visual lookout was not posted
• background shore lights on Moreton Island
• distraction from Charles Darwin’s bright lights
• focus on navigation aid lights (beacons and others)
• relatively low visual and radar detection range of the yacht
• yacht was relatively less conspicuous visually and on radar
• yacht’s radar echo was not identified and actively monitored
• bridge team workload (four course changes in 22 minutes before collision and watch change)
• change in relative bearing of the yacht (and other lights) after each course change
• bridge team members’ focus on individual tasks during that period of high workload
• inattentive lookout for small craft that could reasonably be expected off Moreton Island.

In the time leading up to the collision, the pilot was busy conning the ship. His attention was probably focused on navigation aids, other visual cues, and the ship’s heading and rudder indicator. The helmsman would have been concentrating on executing the pilot’s helm and course orders. The fourth mate was occupied in fixing the ship’s position. The chief mate was probably focused on monitoring the helm orders, their execution, and the ship’s progress in the channel.

While Blazing Keel was not fitted with an AIS unit or a radar reflector to improve detectability (both optional for the yacht), its radar echo and trail were consistently visible after 0400. Therefore, it is reasonable to expect the chief mate (standing beside the radar) to have identified the approaching target. Its lights would also have been visible until less than a minute before the collision (a blind sector existed within a narrow arc of the horizon up to about 150 m ahead of Kota Wajar’s bow).

While a dedicated visual lookout may not have necessarily seen the yacht in those conditions, posting one would have ensured that that person could give their full and undivided attention to the task, including using binoculars. Furthermore, such a dedicated lookout was a requirement of the applicable international rules and standards, and of the ship’s procedures.

Kota Wajar’s bridge team that night for the 3 hour pilotage essentially comprised the pilot, OOW and helmsman. Another seaman to act as a lookout/relief helmsman was not assigned. The fourth mate left the bridge once the pilot boarded and, about 45 minutes later, the master also left.

The evidence indicates that the lack of a dedicated lookout on 6 July was probably usual for that situation. The ship had regularly called at Brisbane and the master had sailed on PIL-managed ships for many years. It is likely that when the duty seaman was the helmsman (day or night) no other person was necessarily assigned lookout duties. The accounts of the bridge team members did not indicate that anyone thought there was no dedicated lookout that night. It is possible that it was considered that the OOW and pilot would sight and detect any traffic.

Conclusion

Key matters with respect to the lookout kept on board Kota Wajar were:

• In the time leading up to the collision, a proper lookout by sight, hearing and all available means, including radar, in accordance with the COLREGS, was not maintained.
• The lack of a dedicated visual lookout, high bridge team workload and local conditions, such as background lights ashore, were factors in the yacht not being detected by sight or radar.
• The ship’s SMS procedures with regard to posting a dedicated visual lookout, consistent with international regulations and standards, were not effectively implemented.

Blazing Keel’s lookout

Blazing Keel’s skipper and his wife both held a Queensland recreational marine driver licence (RMDL). The competency standards^[19] for the RMDL include the application of the COLREGS to ensure safe navigation. The standards pay particular attention to key COLREGS, including Rule 5. Therefore, the skipper and his wife should have been aware of the importance of keeping a proper lookout and how to effectively do so.

On 6 July, the yacht’s radar was not operational and it was not fitted with an AIS unit. The means of keeping a lookout were, therefore, limited to sight and hearing. The skipper and his wife kept a lookout from the yacht’s cabin from where it was not possible to keep an all-round lookout. The cabin’s roof restricted vision in an upward direction and its windows limited visibility. While red lights were being used at the helm position to avoid impacting night vision, the lights in the aft cabin and galley were being clearly reflected by the water.

Blazing Keel’s skipper was navigating using only the electronic chart plotter. The plotter provided a perspective of the yacht’s location with respect to beacons and channels in real time. However, it was of little use in keeping a lookout. With no radar and the self-imposed limitations of keeping a visual lookout from the yacht’s cabin, navigating in darkness inherently involved a higher risk of collision. Further, the skipper was not experienced in navigating the yacht at night. Therefore, in the prevailing circumstances and conditions, a proper lookout was not being kept.

In accordance with COLREGS Rule 22, Kota Wajar’s masthead lights were required to be visible at least 6 miles off, and its sidelights and sternlight at least 3 miles off. Therefore, by about 0355, the ship’s masthead lights should have been visible from Blazing Keel’s location. By 0405, its sidelights should also have been visible. As the yacht’s heading was about 220°, the ship’s relative bearing was nearly abeam to starboard.

By 0410, the ship’s navigation and deck lights should have been clearly visible from the yacht. The ship was 2.2 miles off, just abaft the starboard beam. By 0413, when it was 1.6 miles and abeam, the skipper decided to cross the shipping channel near M7 beacon. At interview, he stated that he and his wife looked but saw no ships in the channel. Therefore, either they could not see Kota Wajar’s lights from their positions in the yacht’s cabin or they did not look in its direction.

By 0415, Blazing Keel was crossing the channel on a south-westerly course. Kota Wajar was about 1 mile off near M5 beacon. Had the skipper or his wife focussed their attention, they would have seen the ship’s lights nearly on the starboard beam. The lights would have become more conspicuous as the ship closed.

By about 0418, the ship’s lights were probably above the line of sight from the yacht’s cabin due to its roof and their considerable height in relation to the yacht. Therefore, it was not unexpected that the skipper and his wife heard the impact of the collision but sighted nothing until the skipper saw ‘the lights of the aft cabin illuminate the hull of a ship’. It was only after the yacht was astern of the ship that the skipper saw the lights at its stern.

The possible reasons why Blazing Keel’s skipper and his wife did not detect Kota Wajar were:

• inadequate visual lookout
• low height of eye (about 2 m)
• backscatter from the yacht’s own lights
• sea spray on the yacht’s cabin windows
• cabin limitations (windows, structures, roof)
• traffic in channel not checked from outside cabin
• ship’s bearing close to abeam (likely focus ahead)
• lack of experience navigating at night (in darkness)
• inexperience identifying a ship’s navigation lights
• not equipped with AIS receiver unit to detect ships
• navigating in darkness without radar (inoperational)
• effects of the time of day (night) and/or reduced sleep
• focus on chart plotter for navigation (passive monitoring)
• focus on crossing channel and course change before the collision
• no active monitoring and visual identification of navigation aids (beacons).

Immediately after the collision, the skipper thought that the yacht had collided with a beacon. Had he been actively monitoring (including visually) the passage, he would have known that his yacht was clear of M7 beacon, the only one in its vicinity. The skipper and his wife’s accounts of the incident indicate that most of the above reasons were relevant that night - it is evident that a proper and effective lookout was not kept.

In summary, a proper lookout by sight, hearing and other means, in accordance with the COLREGS, was not maintained on board Blazing Keel. Undertaking the night passage across Moreton Bay without radar increased collision risk, and was inappropriate. The risk increased further due to the ineffective visual lookout - a significant contributing factor to the incident.

Passage planning

Adequate appraisal and planning for a passage can ensure its safe execution and completion. Planning for a passage, including the proper allocation and use of resources, is a part of bridge resource management (BRM). Effective BRM is the product of a sufficient number of bridge team members with appropriate abilities and skills utilising available navigational aids and tools to carry out planned tasks in accordance with their defined roles and responsibilities. Ideally, this should always be the case but it is particularly important during a pilotage due to the higher risks.

Some important matters applicable to the respective passages of Blazing Keel and Kota Wajar through Moreton Bay on 6 July 2014 appear to have not been properly planned or considered.

Blazing Keel

Blazing Keel’s skipper’s planning focused mainly on arriving off Curtin Artificial Reef in daylight on 5 July, resting overnight and diving on the reef on the following day. He intended to follow the usual tracks to and from the reef, which were saved on the yacht’s chart plotter.

The fact that the yacht’s radar had not been operational for more than a year indicates that the skipper had not planned for contingencies, such as navigating in darkness. Nor had the weather and wind conditions that could be expected been properly considered.

The skipper believed that the easterly winds as the yacht sailed to Moreton Island on 5 July (Saturday) would continue over the weekend. However, by sunset, westerly winds had set in across the bay as could be expected in the evening and night. When Blazing Keel’s anchor chain began paying out as the clutch began slipping under load in the early hours of 6 July, the skipper decided to return to the marina. No other options, such as using more anchor chain to reduce the load, re-anchoring in another position, waiting for daylight or seeking a more sheltered place, were considered.

The long passage across Moreton Bay in darkness without radar involved a high risk to the yacht and its crew. Considering other options would have been prudent, primarily in terms of making an informed decision on whether taking the risks associated with the night passage across Moreton Bay was appropriate. As it happened, the weather conditions remained much the same and, by mid-morning, had moderated.

The skipper turned on Blazing Keel’s combined lantern in addition to other navigation lights. The combined lantern indicated a sailing vessel, whereas the yacht was a power-driven vessel at the time. While the skipper might have intended to make the yacht more readily visible, it was not displaying the lights as required by the COLREGS. Had the yacht been sighted by Kota Wajar’s bridge team, there would have been confusion in correctly identifying it as a power-driven vessel.

It is evident that there was no intention to keep a visual lookout from outside the cabin that night, including when approaching and crossing the shipping channel. Had the skipper and his wife properly checked for ships in the channel, they would have seen Kota Wajar about 1 mile off.

After the collision, the skipper used the handheld VHF radio to make an all-ships broadcast. The limited range of the radio probably contributed to the broadcast not being heard.

The evidence generally indicates that Blazing Keel’s trip was not properly planned nor were contingencies considered. Navigating at night without radar involved a particularly high risk. Proper and complete planning would have reduced risk and might have prevented the collision.

Kota Wajar

A berth-to-berth passage plan had been prepared for Kota Wajar’s voyage to Brisbane, where it had called regularly. The plan was documented using the standard forms in the shipboard SMS. The detailed plan covered many subjects and had been signed by the master and all the mates.

The plan did not include any specific reference to the composition of the bridge team. The standard ‘Pre-voyage passage plan checklist’ included two checks that could be considered to indirectly refer to precautions related to this subject. Check item 05 stated ‘Day/night passing of dangerous points considered’ and item 09 stated ‘Traffic – Area of congested water and narrow channel identified’. The checklist for the passage indicated that these checks were completed.

The remarks included in the plan for each leg of the passage were probably intended to adequately address items 05 and 09. The remarks for the legs of the pilotage where the collision occurred were identical and stated:

Narrow channel-Echo sounder on, when passing each buoy posn mark on chart and note down time in bell book or echo sounder log book. Keep clear reef & rock & Nogo area as marked on the charts. ISM checklist B08, & (B07, B09 as req.) (Vsl. under pilotage, D.off to assist pilot and master)

While the passage plan did not refer to the bridge team’s composition or a dedicated lookout, the ship’s procedures for watchkeeping arrangements (discussed earlier) were clear on this subject. However, a dedicated lookout was not posted. Specific remarks in the passage plan about traffic and keeping a lookout may have prompted greater vigilance during the pilotage. Similarly, taking into account the guidance for masters and mates of ships operating in Australian waters as per Marine Notice 17/2014, titled ‘Sound navigational practices’,^[20] may have helped. The notice also lists their responsibilities when a pilot is on board, the first of which is to maintain a good lookout and situational awareness.

Brisbane Marine Pilots

The pilot used the standard BMP passage plan for Kota Wajar. The standard plan listed a number of OOW responsibilities. The first of these stated ‘Keep a good look out visually and on radar. Use ARPA and report targets to pilot including small fishing boats and yachts’. Excluding this general statement, the plan did not refer to traffic or areas where vessels, including small craft, were likely to be encountered. Neither was the subject discussed in the master-pilot information exchange.

While there are a number of reasons why the yacht went undetected, the pilot’s passage plan and local knowledge input may have increased the bridge team’s awareness of traffic in certain areas. The passage off Moreton Island is one such area where a greater number of small craft can be encountered. The island is a popular recreational area and activities include camping, fishing, parasailing, snorkelling and diving. The waters to the north of Cowan Cowan Point include Curtin Artificial Reef and those south of it include the Tangalooma wrecks. A number of suggested routes for small craft lie adjacent to, or cross, the shipping channel off the island. The area is also one where background lights can affect the visibility of targets in the foreground. Furthermore, the course changes required in the shipping channel increase the bridge team workload.

Although the master is responsible for ensuring a proper lookout is kept, the pilot jointly manages risk during pilotage. Given the pilot’s primary role is providing local knowledge, it then follows that information with respect to local traffic to better manage associated risks should be a priority.

In submission to the draft of this investigation report, BMP advised that interaction with other vessels, particularly small craft, was discussed amongst its pilots and reviewed by its risk management team. The team concluded that such interactions occur throughout the pilotage and, therefore, highlighting any particular area in its passage plan would not effectively address the risk. However, BMP stated that it would consider a range of other measures to address the risk.

In this occurrence, BMP’s standard passage plan and the master-pilot information exchange did not draw attention to any areas of higher risk of collision or prompt Kota Wajar’s bridge team to keep a proper lookout. The passage plan and the information exchange did not ensure that the ship’s bridge team was provided with adequate information on local traffic and areas where attention must be paid to other vessels,including small craft.

Collisions between ships and small vessels

In the past 26 years, 63 collisions between trading ships and small vessels have been reported to the ATSB or its predecessor. Of these, 41 have been investigated,^[21] and the failure to keep a proper and effective lookout has been identified as one of the recurrent contributing factors.

While there is no substitute for a proper lookout, small vessels can improve their detectability with aids such as AIS transceivers and radar reflectors. An AIS transceiver can also assist small vessel crews in the early detection of ships and provide important dynamic and static ship information.

Collisions can also be prevented if navigators on ships and small vessels exercise greater caution in areas where they are likely to encounter each other. In addition to ports, harbours and coastal waters in general, it is important to be particularly vigilant in specific areas. For example, ships should be expected in charted shipping channels, recommended routes, two-way routes, deep water routes, preferred tracks, traffic separation schemes and other similar fairways. On the other hand, small vessels are more likely to be encountered near the shore and in recreational areas, such as reefs, diving areas and fishing grounds.

Navigators today have comparatively easy access to information. For example, electronic chart plotters are common even on small craft and provide accurate information such as the locations of shipping channels. A small vessel that avoids a shipping channel significantly reduces the risk of collision with a ship.

While measures to prevent collisions might appear straightforward, the recurrent contributing factors in collisions between ships and small vessels indicate that implementing such measures is not. The contributing factors invariably include a failure to keep a proper lookout on board one or both vessels and the absence of early and appropriate action to avoid collision.

The past 26 years of safety investigations into collisions between trading ships and small vessels on the Australian coast have consistently shown that keeping a proper lookout and taking early avoiding action in accordance with the COLREGS could have effectively prevented those collisions in almost every instance.

The safety lessons from those investigations have been published in ATSB investigation reports. A number of ATSB safety bulletins also highlight these risks to educate seafarers and mariners. These documents and other safety information about marine safety issues are available on the ATSB website.

__________

13. International Maritime Organization (IMO), London, 2011, Standards of Training, Certification and Watchkeeping for Seafarers (STCW) Code.
14. ibid. Chapter VIII, Part 4-1 – Principles to be observed in keeping a navigational watch, Lookout, Paragraphs 14 to 17.
15. International Chamber of Shipping (ICS), London, 2007, Bridge Procedures Guide, Fourth Edition 2007.
16. Pacific International Lines (PIL), Safety Management Procedure Manual, Chapter 15, Key Shipboard Operation Procedures, Rev 00, 1 May 2004.
17. ibid. Section (D) – Lookout, Page 4 of 43.
18. ibid. Section (N) – Watch-keeping Personnel, Page 13 of 43.
19. Department of Transport and Main Roads, Queensland, August 2014, BoatSafe Competency Standard.
20. Australian Maritime Safety Authority (AMSA), Marine Notice 17/2014, Sound navigational practices, AMSA, Dec 2014.
21. ATSB investigation 320-MO-2015-003 started on 25 June 2015 was ongoing at the time of finalising this report.

Findings

At about 0419 on 6 July 2014, in clear visibility at night, the container ship Kota Wajarcollided with the yacht Blazing Keel in Moreton Bay. The ship was southbound in the shipping channel while the yacht was crossing it. The yacht suffered damage but its watertight integrity was maintained and the two persons on board were not injured.

From the evidence available, the following findings are made. These findings should not be read as apportioning blame or liability to any particular organisation or individual.

Safety issues, or system problems, are highlighted in bold to emphasise their importance. A safety issue is an event or condition that increases safety risk and (a) can reasonably be regarded as having the potential to adversely affect the safety of future operations, and (b) is a characteristic of an organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operating environment at a specific point in time.

Contributing factors

• A proper lookout, in accordance with the international regulations for preventing collisions at sea (COLREGS), was not maintained on board Kota Wajar. A dedicated visual lookout was not posted and radar was not appropriately used.
• Kota Wajar’s safety management system procedures with regard to posting a dedicated lookout were not effectively implemented.[Safety issue]
• The high workload of Kota Wajar’s bridge team and local conditions, such as background lights ashore, were factors in Blazing Keel not being detected by sight or radar.
• A proper lookout, in accordance with the COLREGS, was not maintained on board Blazing Keel. The yacht was navigating at night without radar and the lookout kept by sight was ineffective.
• Blazing Keel’s diving trip was not properly planned, contingencies were not considered and the night passage was undertaken without radar since the equipment had been inoperational for more than a year.

Other factors that increased risk

• All of Blazing Keel’s available navigation lights, including the combined lantern permitted by the COLREGS for sailing vessels, were turned on. As the 13.4 m yacht was a power-driven vessel at the time, the lights displayed were not in accordance with the rules and confusing.
• The inclusion of specific remarks in Kota Wajar’s passage plan with regard to traffic and keeping a proper lookout may have prompted greater vigilance during the pilotage.
• Brisbane Marine Pilots’ standard passage plan and master-pilot exchange did not ensure that a ship’s bridge team is provided adequate information with respect to local traffic and areas where attention must be paid to other vessels, including small craft. [Safety issue]
• Over the past 26 years, investigations into 41 collisions between trading ships and small vessels on the Australian coast have identified that not maintaining a proper lookout and taking early avoiding action, in accordance with the collision regulations, has been a consistent and continuing contributor to such collisions. [Safety issue]

Other findings

• Fitting Blazing Keel with an automatic identification system (AIS) transceiver would have improved its detectability and detection range while allowing those on board the yacht to detect and identify ships at long ranges.

Safety issues and actions

The safety issues identified during this investigation are listed in the Findings and Safety issues and actions sections of this report. The Australian Transport Safety Bureau (ATSB) expects that all safety issues identified by the investigation should be addressed by the relevant organisation(s). In addressing those issues, the ATSB prefers to encourage relevant organisation(s) to proactively initiate safety action, rather than to issue formal safety recommendations or safety advisory notices.

Depending on the level of risk of the safety issue, the extent of corrective action taken by the relevant organisation, or the desirability of directing a broad safety message to the marine industry, the ATSB may issue safety recommendations or safety advisory notices as part of the final report.

Where relevant, these safety issues and actions will be updated on the ATSB website as information comes to hand. The initial public version of these safety issues and actions are in PDF on the ATSB website.

Proper lookout

Kota Wajar’s safety management system procedures with regard to posting a dedicated lookout were not effectively implemented.

Issue number: MO-2014-006-SI-01

Passage planning

Brisbane Marine Pilots’ standard passage plan and master-pilot exchange did not ensure that a ship’s bridge team is provided adequate information with respect to local traffic and areas where attention must be paid to other vessels, including small craft.

Issue number: MO-2014-006-SI-02

Collisions between ships and small vessel

Over the past 26 years, investigations into 41 collisions between trading ships and small vessels on the Australian coast have identified that not maintaining a proper lookout and taking early avoiding action, in accordance with the collision regulations, has been a consistent and continuing contributor to such collisions.

Issue number: MO-2014-006-SI-03

Sources and submissions

Sources of information

On 6 July 2014, ATSB investigators attended Kota Wajar while the ship was berthed in Brisbane. The master and directly involved crew members each provided their accounts of the time of the collision. Photographs of the ship and copies of relevant documents, including log books, reports, records, manuals and procedures were obtained. The voyage data recorder was downloaded.

The pilot provided his account of the time of the incident at the offices of Brisbane Marine Pilots (BMP). The investigators also attended Blazing Keel, where the skipper and his wife provided their accounts of the collision. Photographs and relevant information was obtained. Further evidence was provided by the Queensland Police Service (QPS) and Maritime Safety Queensland (MSQ).

References

Australian Maritime Safety Authority (AMSA), Marine Notice 17/2014, Sound navigational practices, AMSA, Dec 2014.

ATSB, Safety Bulletin 1, Ships and fishing vessels

ATSB, Safety Bulletin 2, Ships and fishing vessels, an open letter to all masters and bridge watchkeepers

ATSB, Safety Bulletin 5, Fisherman and Safety Awareness at Sea

Department of Transport and Main Roads, Queensland, August 2014, BoatSafe Competency Standard.

International Chamber of Shipping (ICS), London, 2007, Bridge Procedures Guide, Fourth Edition 2007.

International Maritime Organization (IMO), London, 2011, Standards of Training, Certification and Watchkeeping for Seafarers (STCW) Code.

IMO, The International Convention for the Safety of Life at Sea, 1974, as amended.

IMO, The International Regulations for the Prevention of Collisions at Sea, 1972, as amended (COLREGS).

Submissions

Under Part 4, Division 2 (Investigation Reports), Section 26 of the Transport Safety Investigation Act 2003, the ATSB may provide a draft report, on a confidential basis, to any person whom the ATSB considers appropriate. Section 26 (1) (a) of the Act allows a person receiving a draft report to make submissions to the ATSB about the draft report.

A draft of this report was provided to Kota Wajar’s master, chief mate, fourth mate, helmsman, its managers, Pacific International Line (PIL), the pilot, BMP, Blazing Keel’s skipper, the Australian Maritime Safety Authority (AMSA), QPS, MSQ and the Maritime and Port Authority of Singapore (MPA).

Submissions were received from Kota Wajar’s master, PIL, the pilot, BMP, Blazing Keel’s skipper, AMSA, MSQ and MPA. The submissions were reviewed and where considered appropriate, the text of the report was amended accordingly.

Purpose of safety investigations The objective of a safety investigation is to enhance transport safety. This is done through: identifying safety issues and facilitating safety action to address those issues providing information about occurrences and their associated safety factors to facilitate learning within the transport industry. It is not a function of the ATSB to apportion blame or provide a means for determining liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action. Terminology An explanation of terminology used in ATSB investigation reports is available here. This includes terms such as occurrence, contributing factor, other factor that increased risk, and safety issue. Publishing information  Released in accordance with section 25 of the Transport Safety Investigation Act 2003 Published by: Australian Transport Safety Bureau © Commonwealth of Australia 2015 Ownership of intellectual property rights in this publication Unless otherwise noted, copyright (and any other intellectual property rights, if any) in this report publication is owned by the Commonwealth of Australia. Creative Commons licence With the exception of the Coat of Arms, ATSB logo, and photos and graphics in which a third party holds copyright, this publication is licensed under a Creative Commons Attribution 3.0 Australia licence. Creative Commons Attribution 3.0 Australia Licence is a standard form licence agreement that allows you to copy, distribute, transmit and adapt this publication provided that you attribute the work. The ATSB’s preference is that you attribute this publication (and any material sourced from it) using the following wording: Source: Australian Transport Safety Bureau Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you wish to use their material, you will need to contact them directly.

Safety summary

What happened

On 11 July 2014, train ST24, a scheduled XPT passenger service, returning to Sydney Central Station from Melbourne Southern Cross Station, derailed at turnout MYD887 near North Melbourne station in Victoria. Turnout MYD887 was installed as part of the Regional Rail Link project. While certified for standard gauge revenue operations earlier that week, it had not been used by XPT services until the day of the derailment.

As a result of the derailment, there were minor injuries to some passengers and the train’s crew, as well as damage to track and rolling stock.

What the ATSB found

The ATSB found that the derailment of ST24 occurred at a type 37 mixed gauge turnout (MYD887), as the wheelset of a carriage (probably XAM2176) transitioned from the standard gauge short stock rail onto the broad gauge switch blade through the transfer area. It was determined that there were design deficiencies of the type 37 turnout with respect to transfer area width, guard rail protection, and capacity of the tie bar to resist elongation, that contributed to the derailment.

Earlier that morning the same train, travelling from Sydney as ST21, derailed at a similar type 37 mixed gauge turnout (MYD882) but re-railed a short distance later. The train crew felt the train bounce but were unaware that it had derailed, so continued into Southern Cross Station. The incident was reported to operational staff and the track was being inspected at the time ST24 derailed at turnout MYD887.

Post-derailment, an examination of the type-approved design of the type 37 turnout determined that it was lacking, in that it had been assumed that the type 37 turnouts would perform safely in service based solely on the performance of a similar (type 29) dual gauge turnout, although there were significant differences between the two turnout types.

The ATSB determined that there were no maintenance deficiencies with train ST24 that contributed to the derailment.

What's been done as a result

V/Line has actively managed the redesign, alteration and validation of the type 37 turnout, to support the safe operation of standard gauge rolling stock having wheel rim widths of 127 mm, including a comprehensive review of contractual arrangements, testing and commissioning processes.

Safety message

Proposed infrastructure changes, including those put forward by contractors, need to be thoroughly assessed at the design stage to ensure that they meet all operational and safety requirements.

Once constructed, infrastructure needs to be rigorously tested as part of the commissioning process to ensure that the changes are safe and perform to the original design intent.

What happened

On 3 July 2014, at about 1940 Eastern Standard Time an instructor and student pilot of a Bell 206 helicopter, registered VH-XJA (XJA), approached Sunshine Coast Airport, Queensland to conduct night circuits. An Airbus A320 aircraft, registered VH-VGJ (VGJ), was inbound to Sunshine Coast from Melbourne, Victoria via the area navigation (RNAV) required navigation performance approach to runway 18. When about 30 NM from Sunshine Coast, the first officer of VGJ broadcast on the common traffic advisory frequency (CTAF), inbound and did not receive a response.

When about 10 NM from the runway, on a downwind leg and approaching a base turn for runway 18, the first officer broadcast on the CTAF that VGJ had left 3,800 ft and was conducting an instrument approach to runway 18, expecting to land at time 2001, and did not receive a reply.

The instructor of XJA heard the call from VGJ and assumed that the aircraft was then about 15 NM away. He expected the crew of VGJ would subsequently broadcast when 10 and 5 NM from the runway, and he elected to continue the circuit and monitor the CTAF for those calls.

The instructor of XJA broadcast when on a 3 NM final, but the crew of VGJ did not hear this call. About 70 seconds later, the first officer of VGJ broadcast on a 2 NM final. Hearing this call, the instructor of XJA turned and sighted the landing lights of VGJ close behind, diverged to the right and commenced a climb. Radar data indicated that the two aircraft passed at an altitude of about 200-300 ft with a lateral separation of about 370 m.

This incident highlights the importance of using both unalerted and alerted see-and-avoid principles and maintaining a vigilant lookout at all times.

Aviation Short Investigations Bulletin - Issue 36

What happened

On 9 July 2014, the pilot of a Cessna 210 aircraft, registered VH-SKQ, conducted a scenic charter flight from Broome, Western Australia, to Windjana Gorge, Silent Grove, Mt Hart Station, Cape Leveque and return to Broome, with five passengers on board.

When approaching Broome Airport, the aircraft was cleared by air traffic control (ATC) to turn onto a left base leg for runway 10. Due to another aircraft backtracking on the runway, the pilot was directed by ATC to extend the base leg. The pilot then selected 10° of flap and the landing gear lever to the extended position, and reported that he had observed the green light indicating the landing gear was extended.

When on the final leg of the approach, the pilot reported that he performed the final checks however omitted to look outside and visually confirm by sighting the left main landing gear, whether the gear was in the extended position. As the pilot flared the aircraft for landing, he realised that the aircraft was lower to the ground than normal on touchdown, and heard what he believed were the main tyres contacting the runway, followed by the aircraft belly and propeller. The aircraft sustained substantial damage.

A witness observed the aircraft on the base leg, with the nose landing gear extended and the main landing gear retracted.

An engineering inspection found that a faulty nose gear up lock switch resulted in the nose gear extending during flight. This resulted in the main landing gear failing to extend. The pilot was unaware that the main landing gear had not extended prior to landing as the visual check was omitted.

Aviation Short Investigations Bulletin - Issue 36

Safety summary

What happened

On 7 July 2014, Genesee & Wyoming Australia train 24KW departed from Iron Duke, a mine site near Whyalla, South Australia. The train was loaded with iron ore destined for the port of Whyalla. Shortly after the train entered the Iron Baron to 21km Junction section, the driver felt a slight ‘bump’ and noticed a loss in brake pipe pressure, before observing a large cloud of dust toward the rear of the train. Once the train had come to a stand the driver walked back along the consist and saw several wagons had derailed, resulting in significant track damage.

What the ATSB found

The ATSB found that two mechanical fishplate joints located at the 108.100 km mark had failed under the passage of the train. The joints failed due to a combination of pre-existing fatigue cracks in the fishplates, and at least one joint being in a condition of weakened structural integrity due to inadequate fastening. As the rollingstock passed over the incomplete and ineffective rail joints, joint instability and movement produced increasing impact forces, lateral pressure and subsequent joint separation. This was followed by the progressive failure and misalignment of the track until the wagons of train 24KW inevitably derailed.

Other fishplated joints within the immediate vicinity of the 108.100 km mark were also examined. While some bolts were missing, examination of the bolt holes suggested that four fasteners had been used to secure the joints. Based on the evidence available, the ATSB concluded that the deficient permanent mechanical rail joint installed at the 108.100 km mark was an isolated anomaly and not indicative of the assembled condition of other plated joints.

What's been done as a result

Shortly after the derailment, Genesse & Wyoming Australia, through a welding program, removed all the mechanical joints within the Whyalla Narrow Gauge mainline network.

In addition to the welding program, GWA and Transfield Services Australia completed an audit of maintenance standards and processes - focussed on improving instructions relating to joint inspection, maintenance and risk reporting. In November 2014, Transfield Services Australia, in cooperation with GWA, disseminated the document Mechanical Joint Rectification to all track maintenance staff.

Following an internal investigation and an incident cause analysis study into the derailment of train 24KW, GWA identified corrective actions associated with installation, inspection and maintenance of mechanical rail joints. GWA have made significant progress implementing those recommendations.

Safety message

To ensure fishplate joints are correctly installed and joints are not compromised during operation, track infrastructure owners and operators should ensure that track maintenance staff are provided with sufficient guidance and instruction for all works requested.

Track managers should ensure the effective application of policy and procedures relating to the assurance of the structural integrity of track joints - before returning the joints to service.

What happened

On 3 July 2014, a Piper Aircraft Corp PA-28-161, registered VH-TEK, was returning from the training area via the 2RN reporting point to Bankstown Airport, New South Wales. The student pilot was the only person on board. The flight was conducted in visual meteorological conditions.

The student tracked from the 2RN reporting point and joined downwind for a touch-and-go landing on runway 29L. The student turned onto base and then final and the Bankstown tower gave the student a clearance to conduct a touch-and-go clearance. The student reported that the approach and landing were normal. As soon as the student felt the aircraft wheels were on the ground, he reached down to the flap lever and selected the flaps to the retracted position.

The aircraft veered slightly to the right and then quickly to the left, departing the runway and onto the grass strip. The student regained control of the aircraft and informed the tower of what happened, reporting that he did not require assistance. The student then taxied onto taxiway B, between taxiway B4 and B3, passing about 20 metres in front of a taxiing Cessna 150. TEK taxied to the flying school without further incident. The student pilot was uninjured, and the aircraft was not damaged.

Aviation Short Investigations Bulletin - Issue 38

What happened

At about noon on 3 July 2014, an instructor and student were conducting training in the circuit at Roma Airport, Queensland, in a Skyfox Aviation CA25N aircraft, registered 24-3265. At the same time, a PA-28R, registered VH-WJO, was inbound to Roma Airport for a landing. The conditions were fine and clear.

As the PA-28R approached the airport, the CA25N instructor and the pilot of the PA-28R exchanged information regarding their respective positions and intentions on the Roma Airport Common Traffic Advisory Frequency (CTAF). During this exchange of information, the pilot of the PA-28R inadvertently miscommunicated his position, which left the CA25N instructor with an inaccurate perception of the position of the PA-28R and a misunderstanding with respect to the intentions of the PA-28R pilot. Similarly, based upon his interpretation of the information exchanged on the CTAF, the PA-28R pilot believed that he would be clear of the CA25N as he joined the circuit.

Despite their efforts, the CA25N crew and the PA-28R pilot were unable to sight the other aircraft until the downwind leg of the circuit when the CA25N instructor saw the PA-28R pass from left to right, about 100 metres ahead and about 200 ft above the CA25N. The CA25N instructor was then able to inform the pilot of the PA-28R of the relative position of the CA25N, allowing the pilot of the PA-28R to then sight the CA25N over his left shoulder. Both aircraft then continued for an uneventful landing, the CA25N landing ahead of the PA-28R which flew a wider circuit.

Although the CA25N instructor and PA-28R pilot were communicating on the CTAF and attempting to establish visual contact, separation seems to have been compromised on this occasion due to the limited effectiveness of the CTAF communications and the limitations of each pilot’s lookout. Lookout effectiveness was probably compromised by a combination of CTAF miscommunication, the geometry of the event and sun glare.

This incident highlights the importance of an effective lookout, and accurate and timely communication. These are fundamental pillars supporting the principles of alerted see-and-avoid.

Aviaiton Short Investigations Bulletin - Issue 37