At about 1806 on 14 August 2004, three seamen on the forecastle head of the container ship Aotearoa Chief were struck by a wave that broke over the ship's port bow. One man was thrown against the windlass and mooring machinery and suffered injuries from which he later died. Another sustained severe lacerations to one leg while the third man was unhurt.

Abstract

On 25 September 2004 the general cargo ship Mellum arrived at Thevenard, South Australia, loaded cargo and on 28 September sailed for Melbourne.

At about 1217 the ship cleared Yatala Channel beacons one and two at a speed of about seven knots. Shortly thereafter the pilot disembarked as the ship approached the entrance beacon. Once the pilot had disembarked the master ordered the helmsman to steer a course of 222° by gyro compass.

At 1233, the ship grounded with the entrance beacon bearing 005½°, at a range of 0.52 miles.

The master de-ballasted the ship and with the assistance of the pilot, who had reboarded, refloated the ship. At 2309 the pilot reported that the ship was afloat.

At 1606 on 30 September, Mellum weighed anchor and sailed for Melbourne after it had been checked for damage and seaworthiness. The report found that a misunderstanding between the master and pilot and a lack of planning by the ship's crew were contributing factors. The master/pilot information exchange was found to be deficient. It was also found that the insets and scales of the navigational chart in use and the choice by the pilot to disembark before the ship arrived at the pilot boarding ground may have contributed to the grounding.

The report makes a recommendation relating to pilot training and practices.

Summary

At 2304 on 7 August 2004, the 34.56 m passenger vessel True North, with 38 people on board, ran aground in the entrance passage to St. George Basin in Western Australia's Kimberley region. At the time of the grounding, the master was alone on the bridge. The vessel was in automatic navigation mode with course adjustments initiated by means of a GPS navigation system linked to an Electronic Chart System (ECS), that transmitted course adjustment information to an autopilot. No pollution resulted from the grounding, although several passengers received minor injuries during the initial impact.

True North had draughts of 1.5 m and 2.2 m forward and aft respectively and remained aground for about one hour. It floated clear of the rock on which it had grounded on the incoming tide and moved under its own power to an anchorage south of one of the islands in St. George Basin. The vessel was beached by the master on the morning of 8 August and a full appraisal of the damage made.

On 9 August, a repair team and equipment was flown to the vessel by float plane from Broome, Western Australia. The passengers and non-essential crew were then flown to Broome and repair work commenced. Temporary repairs were carried out while the vessel was beached in between the periods of high water. These repairs were completed by 11 August and True North departed St. George Basin for Darwin, where permanent repairs were to be effected.

The vessel arrived at repair facilities in Darwin on 14 August. True North was able to depart Darwin for Wyndham on 26 August to resume its cruise schedule.

The report concludes that:

• True North grounded on or near Strong Tide Point in unsurveyed waters while being navigated by an auto helm unit and ECS receiving position information from GPS satellites.
• GPS derived positions plotted on the ECS differed from the vessel's true position, possibly caused by:
  • GPS system inaccuracy;
  • Geodetic datum ambiguity;
  • The ECS operating on a common user personal computer which allowed possible corruption of the ECS operating system;
  • A change in the GPS receiver parameters;
  • Loose wiring or connections in the on board systems; or
  • A combination of the above.
• Too much reliance was placed on the accuracy of GPS positions and the GPS positions plotted on the vessel's ECS were not adequately checked by other navigational means.
• A proper lookout was not maintained by visual, radar and other means to ensure the vessel remained in safe water.
• At the time of the grounding, it is probable that the master was suffering from some effects of fatigue as a result of his work routine.
• There were deficiencies in the procedures which dealt with the mustering of passengers in that:
  • The initial safety briefing was not sufficiently comprehensive;
  • company orders in respect of lifejackets and emergency signals were not followed; and
  • company practices in the provision of emergency information and procedures did not meet WA legislative requirements.

The report recommends that:

• Owners and operators of vessels running Electronic Chart Systems should do so on dedicated computers.
• Owners, operators and masters of vessels regularly operating in confined waters should revise procedures governing the use of GPS and auto pilot systems.
• Owners and operators of passenger vessels should ensure information concerning muster areas, emergency signals and instructions and diagrams of how to don lifejackets, are included in any passenger information kits in cabins, and on the inside of all cabin doors, in order to comply with state/territory regulations.
• True North Cruises should review the procedures associated with passenger briefings and the emergency information displayed in the passenger cabins and vessel common rooms.
• Owners, operators and masters of non-SOLAS vessels should consider the introduction of effective fatigue management policies and practices on board vessels.
• AMSA and state/territory marine authorities should carefully consider the type of operation and area of operation when determining the safety manning of vessels of any length.
• Western Australia's Department of Planning and Infrastructure should consider recommending the amendment of WA marine legislation to allow for the option to review and, if necessary, change the safety manning requirements for state registered vessel.

Executive summary

On 3 June 2004, the Australian sail training ship Windeward Bound was off the Victorian coast, heading northeast at about six knots. The wind was from the northwest and the vessel was heeled between 10 and 15 degrees to starboard. The upper and lower topsails and the main and fore staysails were set. A cold front was expected that afternoon. The watch officer was assisted by a watch leader and two general purpose hands, one of whom was at the helm.

At 1726, when the ship was about 30 miles south of Gabo Island, the wind speed increased. The helmsman was instructed to run the vessel downwind. Shortly thereafter, the vessel yawed to port and the helmsman put the rudder hard over to starboard. The watch leader then took the helm and, as the vessel was now swinging to starboard, applied a 'considerable amount' of port rudder. When the vessel had started to swing to port, the watch leader put the rudder hard over to starboard to arrest the swing. A gust of near-hurricane force wind then heeled the vessel about 68 degrees to starboard.

The starboard side of the main deck was submerged, and seawater entered a fuel tank through an open-air pipe on deck. A quantity of seawater also entered the deckhouse and accommodation before doors to the deckhouse and accommodation were shut. The vessel was righted after several minutes using the main engine and rudder and by letting the sheets go.

There was a minor injury to a crew member during the incident and the main engine had been damaged after being run with little or no lubricating oil pressure when the vessel was heeled.

During the next twenty-four hours contact was lost with authorities ashore. An air search was initiated in the afternoon on 4 June and Windeward Bound was found safe and heading for Jervis Bay, where it arrived late in the evening on 5 June.

At 0244 on Tuesday, 29 June 2004, the fishing vessel Ocean Odyssey collided with the container ship P&O Nedlloyd Taranaki in the approaches to Port Botany, New South Wales. At the time of the collision P&O Nedlloyd Taranaki was 'not under command'¹ with a main engine breakdown and was in a position with Cape Banks light bearing 327(T) by 4.7 miles. Ocean Odyssey sustained damage to its hull and deck in the collision and returned to Sydney immediately for repairs. P&O Nedlloyd Taranaki sustained only slight scratching to the paintwork on the ship's side.

¹ 'Not under command', means a vessel which through some exceptional circumstance is unable to manoeuvre as required by the International Regulations for the Prevention of Collisions at Sea, 1972, and is therefore unable to keep out of the way of another vessel.

Summary

At about 0200 on 16 April 2004, the duty engineer on board the Panama registered bulk carrier Harmonic Progress discovered that the main ballast line was leaking, and the engine room bilge was filling with the ballast water. Despite an immediate temporary repair and utilising pumps to try and clear the bilge, the water level continued to rise until it reached a height at which it caused an electrical short in both main engine lubricating oil pump motors, which disabled the main engine.

The master reported the engine room flooding to the ship's managers who arranged for two tugs to take the ship in tow. The ship was in the Coral Sea, approximately 90 nautical miles north of Hydrographers Passage, when it became disabled. During the 43 hours the ship drifted, prior to the arrival of the first tug, it covered 104 nautical miles in a westerly direction. During the time adrift, the ship came to within 30 nautical miles of the Great Barrier Reef.

Harmonic Progress was towed to the Queensland port of Gladstone, where initial repairs were undertaken in order to enable the ship to proceed under its own power to Brisbane. At Brisbane, Harmonic Progress entered dry dock, where inspection, repair and testing of ballast valves and pumps took place. No one on board was injured during the incident and no pollution resulted.

The report concludes that:

• A leak in the main ballast line caused the flooding of the engine room to a level in excess of 1.5 m, which led to the main engine lubricating oil pump motors short circuiting and the vessel becoming disabled.
• A combination of corrosion and erosion caused wastage in the main ballast line, which directly led to the leak.
• Leaking butterfly valves in numbers two and three (port) topside water ballast tanks led to the two tanks draining into the engine room via the leak.
• A crossover valve on the main ballast line in the engine room had not been closed after ballast operations.
• The crew did not isolate the leak by checking associated valves early enough to prevent disabling of vessel.
• Early action was not taken to prevent the water level rising to the point where the lubricating oil pump motors short circuited.
• The crew were unfamiliar with the ballast system and did not use a systematic approach to find the source of the water leaking from the ballast line.
• The pre-delivery inspection of the ship prior to the change of ownership is suspected of being inadequate.

The report recommends that:

• Ship operators and managers ensure sufficient time is made available for handover of information to key personnel when changes of crew or ownership take place.
• Ship owners, operators, manager and masters should revise ISM procedures for ballast operations to ensure they are specific to their ships.
• Classification societies should consider the inclusion of regular ballast line thickness testing around known risk areas, such as 'T' junctions during the enhanced survey program for bulk carriers and oil tankers. This is particularly applicable to ships over 15 years of age.
• The IMO should consider including the possibility of engine room flooding contingency in SOPEP manuals.
• Classification societies and owners acquiring existing ships should make it a condition of sale that all the ship's maintenance records are retained on board.

Summary

At 1900 on 26 February 2004, the Bahamas registered passenger ship Astor let go its mooring lines and departed the Queensland port of Townsville.

The ship, equipped with twin rudders, controllable pitch main propellers and a single bow thruster, did not require a tug for the departure. The master, as is common practice on passenger ships, manoeuvred the ship clear of the berth and then, even though this was his first visit to Townsville, kept the conduct of the ship without consulting the harbour pilot. The pilot adopted an advisory role.

As the ship was turning from the harbour into Platypus Channel, part of the approach channel to the port, it grounded on its port side. The ship heeled three degrees to starboard and, after about three minutes, slid clear of the bank without assistance and continued out of the channel.

After it had cleared the channel, the ship stopped for about two hours to check that the hull was not breached and that all machinery was operating normally. Immediately upon notification of the grounding, the Australian Maritime Safety Authority (AMSA) placed a detention order on the ship until the ship's classification society was satisfied that Astor was seaworthy. When it was confirmed that the hull and machinery were in proper condition the detention order was lifted and the ship then proceeded to Cairns. At Cairns, an underwater survey of the hull was carried out to ascertain the extent of any damage.

Based on the available evidence the report concludes that:

• The investigation has been unable to determine the degree, if any, to which a reported steering malfunction contributed to the grounding.

The following factors, however, are considered to have contributed to the incident on 26 February 2004, independently from any steering malfunction:

• The master did not accept the pilot's advice after the ship left the berth.
• Communications on the bridge were in a language the pilot was not able to understand.
• The ship's master and bridge team members did not employ good Bridge Resource Management practices at any time leading up to the grounding.
• The master had not positioned the ship correctly for a turn to starboard into Platypus Channel.
• The master did not present an outward passage plan to any of those present on the bridge at the time of departure.

The investigation into the grounding of Astor was complicated by the fact that Voyage Data Recorder (VDR) data was not backed up in the time immediately after the grounding (highlighting a deficiency in crew training in this important facet of ship operations) and by the fact that company procedures were not followed with respect to the keeping of bridge records.

The investigation showed that crucial VDR information is easily lost by unintentional actions.

Of additional concern to the safety of navigation and the prevention of pollution on the Australian coast is that the master did not declare any steering defect to the Cairns pilot or port authority and Astor entered the Cairns Channel using only one steering motor on the port rudder without the pilot's knowledge.

This reports recommends that:

• Ship owners, managers, operators and masters of ships ensure that all bridge staff are fully trained in the correct operation of VDR data backup procedures for the particular ship on which they are serving.
• Manufacturers of VDR units should ensure that indicator lights are free of any possible ambiguity and that consideration be given to printing emergency backup instructions on VDR control panels on ships' bridges.
• Masters of vessels should not actively con the ship directly during pilotage unless they are familiar with the port and they do so in full agreement with any pilot.
• Ships' masters should ensure that all bridge orders in pilotage waters are in a language understood by pilots and ships' staff.
• Ship owners, managers and operators should instruct masters and ships's to use all elements of effective Bridge Resource Management at all times.

On 11 March 2004, while assisting with cargo hold repairs at anchor off the Queensland port of Hay Point, an engineer cadet fell from a hold ladder, landing on the tank top about ten metres below. He died from his injuries before an emergency medical helicopter, with a doctor on board, landed on the ship.

At about 0400 on the 5 January 2004, the Malaysian flag bulk carrier Bunga Orkid Tiga and the Australian fishing vessel Stella VII collided near Creech Reef in the Great Barrier Reef. This was the twenty-sixth collision between a trading ship and an Australian fishing vessel since April 1994.

Neither vessel was keeping a proper visual lookout in the time leading up to the collision. This report, as do previous ATSB reports regarding collisions, emphasises the need for all vessels to maintain a proper lookout at all times.

Executive summary

Train 6WP2 operated by Pacific National Ltd (PN) derailed at 2222 (central summer time) on Sunday 9 November 2003 as it was passing through Bates, South Australia. The train had departed Port Augusta that morning and was proceeding to Perth, Western Australia.

The derailment was limited to wagon number RKCX24 positioned 21st in a train of 73 wagons. The condition of a Roller Bearing Unit (RBU) on the right hand third axle of the wagon had progressively deteriorated to a point where friction induced heat caused the portion of axle between the RBU and the wheel to become 'plastic ' causing the RBU to seize where upon the axle separated or 'screwed' off as the axle turned.

After approximately 200 metres in this state, the leading end bogie side frame dropped to the outside of the right hand rail. The wheels did not leave the rails until reaching the western end of Bates where the crossing loop points caused a destabilising effect. The train was brought to a stop in just over 1000 metres by the train crew from a speed at the time of derailment of 77 km/h.

Approximately 1,275 metres of track sleepers and 150 metres of rail were damaged as a result of the derailment. No injuries were reported and no dangerous goods were involved.

It was concluded that train 6WP2 derailed due to the failure of a RBU on wagon RKCX24. A number of causal factors relating to bearing roller assembly cage failure were identified in the investigation associated with: bearing refurbishment and assembly; storage; and handling of the wheel set.