There was insufficient evidence to determine the factors that led to the out of trim condition. The aircraft was correctly loaded and well within the centre of gravity envelope. Appropriately qualified maintenance personnel could find no fault with the trim system after a comprehensive check and the aircraft handled normally on the subsequent sectors. The possibility of a mis-set trim was explored and cannot be excluded. The pilot stated that all the appropriate checks before take-off were carried out. The before-take-off checks included setting the trim.

A checklist can be viewed in human factors terms as an additional interface between the human and the machine. That interface controls the method and sequence of the aircraft's configuration. Regardless of the type or method used, the disciplined use of cockpit checklists by pilots is an essential element in flight safety. Distractions and interruptions can break the checklist process and may result in a checklist error or omission. This may be critical in single-pilot operations where the checklist is often the last line of defence against configuration errors. Having ensured that the appropriate training and checking has been carried out, an operator's safety management is dependent on the degree of discipline and professionalism applied to each phase of the operation by the pilot.

Summary

The Malaysian flag container ship Bunga Teratai Satu sailed from Singapore on 26 October 2000, bound for Sydney via the inner route of the Great Barrier Reef with a cargo of 857 containers. A licensed pilot was embarked to conduct the navigation through the inner route between Goods Island and Cairns.

At 0554 AEST on 2 November 2000, Bunga Teratai Satu disembarked the pilot at Yorkeys Knob, off Cairns, at the southern limit of the compulsory pilotage area.

At 0600, 'full away' was rung and the vessel resumed its passage to Sydney on a course of 120° (true). A programmed way-point, at position 16° 52.8' S, 146° 02.3' E, was reached at 0700. At this way-point, the course was supposed to be altered to 164° (true) to round Fitzroy Island and take the vessel to the west of Sudbury Reef. However, no course alteration was made.

The ship was reporting under the Great Barrier Reef Ship Reporting System, REEFREP, administered from Reefcentre, Hay Point. This system requires ships transiting the inner route to report at certain positions within the inner route. To help enforce compliance with pilotage and reporting requirements the normal entry points to the inner route are monitored by radar. In the limited areas covered by radar, the system fulfils a secondary, monitoring role, to improve safe navigation.

Bunga Teratai Satu had been acquired as a target at Reefcentre when it entered the area covered by the Green Island radar system at about 0430. From about 0715 to 0725, the Reefcentre operator was attempting to re-establish lost targets on the Hammond Island radar display covering the western area of Torres Strait. Just before 0716 Bunga Teratai Satu entered the restricted zone (2 miles off Sudbury Reef) but the Reefcentre operator did not notice the alarm message as he worked on other tasks.

At about 0723, the ship struck the north end of Sudbury Reef at a speed of over 20 knots on a heading of 120°. It was about 1 3/4 hours after low water and the vessel's bow rode some 100 metres onto the reef leaving the stern in approximately 12 metres of water.

Nobody was hurt as a result of the grounding and no oil or other pollutant escaped from the ship. The grounding resulted in mechanical damage to the reef and the yet-to-be assessed effects of the ship's anti-fouling paint.

The Australian authorities issued detention orders while the ship's situation was being assessed. Bunga Teratai Satu remained fast on the reef until it was eventually refloated with the aid of tugs at about 0930 on 14 November 2000.

The investigation found that the significant unsafe act that resulted in the grounding was the inattention of the mate on watch aboard Bunga Teratai Satu, who was distracted by his wife's telephone call to their family overseas.

However, a number of other contributing factors led to a breakdown in the defences and protections that may have prevented the ship from grounding.

Conclusions

These conclusions identify the different factors contributing to the grounding of Bunga Teratai Satu and should not be read as apportioning blame or liability to any particular individual or organisation.

1. The significant unsafe act that resulted in the grounding was that the mate allowed himself to become distracted, for a period of about 15 minutes, from the navigation of the ship by a telephone conversation between his wife, who was on the ship's bridge wing, and his family overseas.

2. From about 0645 to 0715 the mate had become preoccupied with arranging and making private telephone calls while the ship was in cellular phone range of the coast, rather than monitoring the ship's course, speed, position and his other watchkeeping duties.

3. The manner in which the mate maintained his watch on 2 November 2000 lacked appropriate motivation and fell well below proper professional standards.

Based on the evidence available, the following underlying, or 'latent', factors are considered to also have contributed or are relevant to the incident:

4. The ship's GPS cross-track error alarm was neither loud enough nor strident enough to attract urgent attention.

5. The absence of an appropriate level of Bridge Resource Management on the vessel allowed a basic error by oneperson to result in a serious accident.

6. The Reefcentre operator was aware that Bunga Teratai Satu was in the area of the Green Island radar coverage, but the loss of radar signal of vessels in Torres Strait caused him to focus solely on the Hammond Island display and to concentrate on re-entering the information into the Traffic Information Module.

7. The frequency of annunciation of Traffic Information Module alarms and associated radar alarm systems had led to the desensitising of Reefcentre operators to the whole TIM alerting system.

8. However, given the setting of the restricted area off Sudbury Reef at two miles and the speed and circumstances prevailing on the bridge of Bunga Teratai Satu, it is unlikely that any advice provided by the Reefcentre operator under the Reefcentre procedures would have prevented the grounding.

In relation to the perception that the radar system was not reliable:

9. The radar units operated consistently within the design availability criteria.

Summary

On 19 October 2000, the Australian Maritime College vessel Wyuna was being used to train students in night pilotage exercises in the Tamar River.

The exercises had commenced before dawn that morning, resuming at 2000 under the master's supervision. An outward passage and an inward passage were satisfactorily completed, and a second outward passage was started.

The tide was ebbing. The sky was overcast with moderate rain, the wind was SSE at force 4/5 and the visibility was moderate to good. During the early stages of the passage out, the master observed that the vessel was overshooting course alteration points. On both occasions he verified Wyuna's position and brought the vessel back on track.

After clearing Northwest Bank beacon, the master became disorientated and confused Northwest Bank Beacon for Shear Rock Beacon. He instructed the student on the con to set a course to take Wyuna clear of the river, but the vessel was set on course for Shear Rock. At 2305, Wyuna struck Shear Rock.

The master stopped the engines and checked the electronic chart display, which showed the vessel on Shear Rock. The tide was setting the ship across the rock but, about 2 minutes later, the ship was afloat once more, being carried northward across the channel.

The master let go the port anchor with a shackle¹ and a half of chain, but this did not arrest the ship's drift and, at 2315, the ship grounded once more, on Middle Bank. The chief engineer reported that there was no apparent damage to machinery, so the master used the engines to prevent the ship from going further aground and, at 2317, Wyuna steamed back into the channel.

The master took the ship back to anchor at Bell Bay while continuing to check the vessel for any damage. No oil or water was lost from the ship, but numbers 10 and 11 double bottom tanks were making water through sprung seams and rivets.

^{_____________
1} A shackle is about 27 metres.

Summary

At 2036 on 5 August 2000, the Philippines flag, panamax bulk carrier, Washington Trader arrived at the anchorage at the Abbot Point coal loader in Queensland. The ship was in ballast and intending to load a full cargo of coal for export to Japan.

While at anchor on 6 August, the master decided to take the opportunity to conduct an emergency steering and fire drill, followed by an abandon ship drill using the ship's totally enclosed lifeboats. At 1600, the crew commenced the abandon ship drill. As there had been a full lifeboat drill some seven weeks previously, the drill involved a boat muster, followed by the lowering of the unmanned lifeboats to deck level.

By 1612, the boat muster had been completed and both lifeboats prepared for lowering. The master ordered the starboard lifeboat to be lowered first and this was completed without incident.

The master then ordered the port boat to be lowered. The mate, who was the officer in charge of the port boat, started lowering the boat by operating the brake release lever on the davit winch. When the boat was approximately halfway to the deck, the master saw the after end of the boat swing and jerk twice followed by the after-fall detaching from its on-load release hook. When the after fall detached, the boat's stern fell and swung forward, and the boat was seen to jerk twice more followed by the forward on-load release hook releasing its fall. The boat then fell stern first approximately 15 m to the water below.

After the incident, the lifeboat was brought back alongside. There was obvious damage to the stern of the lifeboat and a jacobs ladder was rigged to allow the mate to enter the boat to inspect the damage. He found that the boat was flooded and severely damaged at the stern with the canopy broken and set in. He also found that the after deck around the on-load release hook had been damaged by the impact.

After initial unsuccessful attempts to recover the lifeboat, it was secured alongside overnight. It was recovered early the next morning using the auxiliary lifting shackles on the on-load release hook units. The lifeboat was re-stowed in its davit and secured with additional lashing.

Summary

At about 0110 on 21 June 2000, off Evans Head, New South Wales, the skipper of the prawn trawler Sue M and the deckhand were sorting their catch on the after deck. The trawler, on autopilot, was heading east to another fishing ground, when it was struck on the port side by a southbound ship. The skipper ran into the wheelhouse to attempt to take control of the trawler as it rolled over to starboard before capsizing.

The deckhand climbed over the side of the trawler as it capsized and jumped clear before it sank. He eventually climbed into the trawler's fibreglass dinghy which, although badly damaged, had surfaced after breaking loose from the wheelhouse roof. He was rescued the next night by another trawler.

The ship, the Panama flag bulk carrier Star Sea Bridge, had sailed from Brisbane on the morning of 20 June bound for Melbourne. At the time of the collision, the officer of the watch, the second mate, had been manoeuvring to avoid a northbound container ship. As the bulk carrier was resuming its original course, the second mate saw a white light, close by, to starboard. He ordered full port rudder, but the ship made contact with the white light, roughly amidships on the ship's side as its stern swung to starboard. The master of Star Sea Bridge was called to the bridge and the ship was turned about to search the area where the collision had occurred. After searching and finding nothing, the ship resumed its voyage south.

At Melbourne, Star Sea Bridge was boarded by agents of the Australian Federal Police who initiated an investigation and, subsequently, criminal proceedings against the master and the second mate. A concurrent, but separate, safety investigation was undertaken by the Australian Transport Safety Bureau (ATSB) under the provisions of the Navigation (Marine Casualty) Regulations.

An extensive air and sea search was unable to locate the skipper of Sue M. On 22 June 2001, the wreck of Sue M was located by another trawler. A week later, divers from the NSW Water Police recovered the body of the skipper from its wheelhouse.

This report concludes that:

• The fishing vessel Sue M sank, with the loss of its skipper, after colliding with the bulk carrier Star Sea Bridge;
• The second mate and lookout of Star Sea Bridge were not keeping a proper lookout;
• The skipper and the deckhand on the fishing vessel, who had been busy sorting their catch under bright deck lights, were not keeping a proper lookout; and,
• The bulk carrier's navigation lights were probably not on at the time of the collision.

The report recommends that:

• Ships' masters and skippers of fishing vessels should ensure that a proper lookout is maintained at all times;
• Ships' masters, watchkeepers, fishing vessel skippers and crews take note of the limitations of radar;
• Owners, operators and skippers of fishing vessels consider the use of appropriate equipment to improve the radar detectability of their vessels.

Summary

On the afternoon of 30 April 2000, the Kuwaiti flag product tanker Al Deerah arrived off the Tamar River. The tanker was carrying a cargo of gas oil, heating oil and unleaded petrol from Kwinana in Western Australia for discharge at Bell Bay and other Australian ports.

At 1600 a pilot embarked to conduct the ship to the oil berth in Bell Bay. On the bridge with the pilot were the master, the mate and a helmsman on the wheel. The tide was flooding at an estimated two knots. Shortly after boarding, the pilot ordered full ahead manoeuvring speed.

The passage through the entrance of the Tamar River is narrow and there are seven significant alterations of course within a distance of 5.51 miles. As the vessel entered the Tamar River and made the initial course alterations, the pilot found that the ship was sluggish to respond to the rudder. Later, on the Stone Quarry leads, significant angles of counter rudder were required to steady the vessel on course.

At about 1637 the vessel steadied on the Stone Quarry leads, approaching the wheelover position to alter towards the south off Garden Island. At about 1639 the pilot ordered starboard rudder to bring the ship to the next heading. As the vessel altered course to starboard the pilot realised that it was turning too quickly. He ordered the rudder amidships, then to port. However, the vessel continued swinging to starboard, making contact with the bottom off the southeast edge of Garden Island. It heeled to port, then returned upright before listing to starboard.

Al Deerah's cargo tanks are protected by ballast tanks and a check revealed that nos. 2 and 3 starboard combined bottom and side ballast tanks were filling with water. The master ordered that the port ballast tanks be filled to counteract the list.

At 1745, the vessel anchored in Bell Bay. The harbour master boarded the vessel to discuss the situation with the master and the pilot. He disembarked after deciding that it was safe to berth the vessel and Al Deerah was secured at its berth at 2215 without further incident.

Nobody was hurt as a result of the grounding, nor did any oil or other pollutant escape from the ship.

The Australian Maritime Safety Authority (AMSA) detained the vessel at 2240 on 30 April. The detention was lifted at 2100 on 1 May to permit the vessel to sail to Burnie after a classification society surveyor had viewed video footage of an underwater examination of the hull and had issued the vessel with a condition of class. The interim certificate from the class society stated that the vessel was to discharge its cargo at Burnie and Port Botany, then proceed directly to dry dock for repairs.

After discharging its cargo at Bell Bay, Al Deerah left the berth and anchored at Bell Bay at 0034 on 2 May, before sailing for Burnie at 0908 the same day.

Summary

On the morning of 10 April 2000, the 64 957 tonne, Maltese flag, panamax bulk carrier Amarantos was inbound to the port of Wallaroo at the eastern side of the Spencer Gulf, South Australia. The vessel was in ballast and intending to load 20 000 tonnes of wheat for export to Iraq.

The main engine was prepared for the arrival stand-by and tested astern at 0510; the chief engineer was conducting engine manoeuvring from the control room.

A Ports Corp South Australia pilot boarded the vessel outside the Wallaroo entrance channel. At 0612, after the pilot had made his way to the bridge, a pilot/master information exchange took place. The pilot took charge of the navigation and brought the ship on to an easterly heading to enter the port south of the shipping channel.

At 0645, Amarantos was met by the two harbour tugs, Kalanbi and Ungarra, south of the number 11 channel beacons. Kalanbi, the marginally smaller of the two tugs was 'made fast' to the ship's bow and Ungarra to the stern.

Amarantos continued a 'normal' approach to the Wallaroo jetty and, at 0708, the master of the vessel noted the ship's speed at 3 knots ahead with the ship approximately 500 m north-east of the berth. The pilot was turning the ship, at this time, onto a southerly heading to approach the berth nearly at right angles. Off the berth he intended using the tugs and the effect of the transverse thrust of the propeller with the engine going astern, to berth 'port-side-to'.

Despite putting the engine astern and the tugs attempting to turn Amarantos, the ship maintained a nearly steady course. Initially this did not concern the pilot, but with the bow 30 m from the wharf, he ordered all personnel to be cleared from the jetty, as contact seemed inevitable.

At a time logged by the ship's crew as 0720, Amarantos made contact with the Wallaroo jetty causing substantial damage to the jetty deck timbers, piles, and the grain loader and its supporting superstructure mounted on the jetty. The vessel struck the jetty almost at right angles and continued on into the jetty for a distance of 3.5-4 m. The ship sustained only minor non-structural damage in the incident.

Amarantos moved clear of the jetty immediately after the contact and was subsequently berthed by the pilot alongside the number 2 north berth with all lines ashore at 0820.

Conclusions

These conclusions identify the different factors contributing to the incident and should not be read as apportioning blame or liability to any particular organisation or individual.

On 10 April, 2000 the bulk carrier Amarantos stuck the Wallaroo jetty within 15 of the perpendicular as a result of:

1. The pilot misjudged the speed of approach to the jetty.

2. The angle of approach at right angles to the jetty allowed only a minimal margin for error; a more oblique angle would have reduced the risk.

3. The tugs lacked both the manoeuvrability and power to either; arrest the ship's forward momentum and/or swing the ship off the jetty in time to avert the incident.

The following factors are seen as contributing to the incident:

4. The limited under keel clearance, combined with the ship's speed, negated the transverse thrust of the propeller.

5. The propeller was operating with diminished efficiency as a result of incomplete immersion at the ship's aft arrival draught.

6. No formal risk assessment had been completed for the berthing and unberthing of panamax size ships in the port of Wallaroo prior to the incident.

7. There was a lack of proper bridge resource management in that: the master, for the initial period of the pilotage, was more interested in listening to the radio; the pilot neither asked for, nor was told, the ship's speed from the GPS; communications between the master and the pilot were minimal.

Also:

8. The lack of objective evidence and sloppy record-keeping on board Amarantos complicated and extended the investigation.

Summary

On the morning of 25 March 2000, the 39 015 tonnes deadweight, Liberian flag, geared bulk carrier Silver Bin was heading south to Townsville via the inner route of the Great Barrier Reef. An Australian Reef Pilot, who had boarded the vessel at Booby Island the previous evening, was conducting the navigation of the ship. The sea was slight, with an easterly breeze of less than 10 knots, and no swell. The ship was making headway at just under 12 knots. During the morning, visibility had been reduced by an occasional rain squall. On the bridge with the pilot were the master, third mate and a quartermaster who was hand-steering the vessel.

At 1145, 5 miles north of Chapman Island, the pilot had a radio conversation with a yacht in the area. This conversation was overheard by the skipper of Chinderah Star, a prawn trawler, approximately 3.6 miles south of Chapman Island, heading north at 9.2 knots in the shipping channel. The skipper, in the wheelhouse of the trawler, identified the ship on his radar and visually, but did not make radio contact. His two deck hands were asleep in the cabin below.

At 1157 the pilot altered Silver Bin's course to 174° (T) to pass 0.5 miles west of the Chapman Island light. This alteration brought the vessel onto an end-on collision course with Chinderah Star now 4.2 miles away. The bridge team on the ship had not seen the north-bound trawler either visually or on their radars.

After the course change, a rain squall moved into the shipping channel from east of Chapman Island, and enveloped Silver Bin in heavy rain. The crew of the ship estimated the range of visibility in the heavy rain at 160 m. Chinderah Star was also enveloped by the squall and the skipper lost sight of Silver Bin both visually and on radar as a result of rain clutter. The crew on Silver Bin's bridge were still unaware of the northbound trawler in the channel despite their visual and radar watch. Neither vessel altered speed or course. Silver Bin and Chinderah Star collided at 1209, 0.5 miles west of the Chapman Island light, the fishing trawler's starboard side making contact with the ship's starboard shoulder under the flare of the bow. The fishing vessel sustained significant damage to the wheelhouse, the starboard trawl boom and along its starboard side. There were no injuries as a result of the collision.

After the collision, radio contact was established between the two vessels and assistance was offered to the fishing vessel by the ship. This was declined and the ship continued on to Townsville. After retrieving the trawl gear that had been left in the water after the collision, Chinderah Star's skipper contacted the trawler's owner. The decision was made to return to Cairns to repair the collision damage. Both Chinderah Star and Silver Bin arrived at their respective destinations in the early hours of 27 March 2000.

Summary

At about midnight on 18 March 2000, the recreational craft Chester, a half cabin cruiser with the owner and a deckhand on board, was at anchor about 28 miles east of Mooloolaba. No lookout was being maintained on the craft.

Shortly after midnight, when both crew members were asleep, Chester was struck by a ship. After the collision, the skipper found that there was minor damage to the bow and a handrail. The anchor had been lost, but the hull was intact and he anchored once more, using a spare anchor. About an hour later, he weighed anchor and returned to Mooloolaba, then to Brisbane by road with the craft on a trailer, where the deckhand reported the incident to the water police.

The Australian Transport Safety Bureau (ATSB) interviewed the crew of Chester at Brisbane and obtained samples of paint, deposited as a result of the collision, from the starboard rail of the vessel.

The ATSB obtained a surface plot of ships in the area of the collision from AusSAR, the Australian search and rescue organisation. A number of ships on the plot were asked for their positions at the time of the collision and the bulk carrier Hai Teng provided a position close to that of the collision.

Hai Teng had been on a voyage from Newcastle to China at that time. When the vessel returned to Newcastle on 21 April 2000, interviews were conducted by the ATSB with the master, the 2^nd and 3^rd mates and the able-bodied seaman (AB) who had been on watch with the 2^nd mate. The 2^nd mate and AB denied any knowledge of the incident stating that they had not seen any craft near the ship at the time reported for the collision.

The ATSB also obtained paint samples from Hai Teng. The Criminalistics Team, Forensic Services, of the Australian Federal Police at Canberra analysed the paint samples from both vessels concluding, in their report, that there was strong evidence to support the proposition that the Hai Teng and Chester had come into contact.

Sources of Information

Owner and deckhand of Chester

Master, 2^nd and 3^rd mates and lookout, Hai Teng

AusSAR (Australian Search and Rescue)

AMSA (Australian Maritime Safety Authority)

Acknowledgement

Portion of chart Aus 365 reproduced by permission of the Hydrographic Office, RAN

The Criminalisitics Team, Forensic Services, Australian Federal Police

Narrative

The ship

Hai Teng is a Chinese flag bulk carrier of 37 871 tonnes deadweight at a summer draught of 10.763 m. The vessel has an overall length of 187.73 m, a moulded breadth of 28.4 m, and a moulded depth of 15.3 m.

The vessel was built in April 1977 by Ishikawajima Harima Heavy Industries at Aioi in Japan. It was named Adrianople and then Radiant Venture before it was purchased by its present owners, Guangdong Ocean Shipping Co of Guangzhou, China, who re-named it Hai Teng. Hai Teng is classed with the China Classification Society.

Hai Teng has five cargo holds and is equipped with four deck cranes. The bridge, engine room and accommodation are located aft.

The vessel is powered by a single, 6-cylinder Sulzer diesel engine of 7 282 kW and has a service speed of 12 knots. The engine room is manned whilst the vessel is at sea.

Hai Teng had the normal range of navigation equipment, including three radars, of which two were in use. One radar, 3 cm, was manufactured by Tokyo Keiki in 1977 and was fitted with a JRC, JAS - 800 M II, ARPA. A second Japanese radar was not in use. The third radar, fitted in 1998, was a Kelvin Hughes, Nucleus 6000A, 10cm radar with ARPA.

All officers and crew were from China and the officers held appropriate certificates of competency issued by the Chinese Maritime Authority.

The master held a master's certificate as well as radar and ARPA licences. He had been at sea since 1980, as ordinary seaman (OS) and able-bodied seaman (AB) before sailing as 3^rd mate from 1985 until 1989. He was 2^nd mate on bulk carriers, general cargo and container ships from 1989 until 1993 and was chief officer on similar ships from 1993 until 1997. In 1998 he was promoted to master of a bulk carrier and he joined Hai Teng as master on 12 October 1999.

The 2^nd mate had a 2^nd mate's certificate and licences for radar and ARPA. He had been at sea since 1992 as a cadet, then AB and assistant officer, before sailing as 3^rd mate in 1995. He had been a 2^nd mate since 1998 and this was his second trip on Hai Teng. He had earlier sailed on Hai Teng from December 1997 until November 1998 and re-joined the ship in May 1999.

The 3^rd mate had a 3^rd mate's certificate and licences for radar and ARPA. He had been at sea since 1996 as a cadet, OS and AB before he was promoted to 3^rd mate in March 2000.

The AB on watch with the 2^nd mate had been at sea since 1985 as a cadet and OS. He had been sailing as AB for the last ten years.

The three mates maintained 4 on, 8 off sea watches, with an AB assigned to each watch for lookout duties.

The recreational craft

The recreational craft Chester, a half cabin cruiser built in 1986 and registered with Queensland Transport is operated out of Mooloolaba, Queensland.

The vessel has a registered length of 7.4 m, a beam of 2.5 m and a depth of 1 m. The hull and upperworks are of aluminium, painted white.

Chester is fitted with a 175 hp outboard engine driving a single screw. The vessel has a raked stem and a transom stern. There is a wheelhouse and the sleeping quarters are forward of, and below, the wheelhouse. The fishing deck is aft, illuminated at night by two strip lights just above the well-deck level. A white all round light is fitted above the forward end of the cabin.

Navigation equipment included a magnetic compass, GPS, a fish finder/echo sounder and two marine radios. The craft was equipped with an EPIRB.

The owner of Chester has a power boat licence and a licence to operate 27 MHz radio. He was a recreational fisherman and had been fishing for about 20 years, from his father's boat initially, then from his own boat which he bought in 1988. He had not had any previous accidents before this collision.

The deckhand, a recreational fisherman, had no licences. He had worked on charter craft for a few years and had fished with the owner of Chester for about 4 years.

The Incident

Hai Teng

Hai Teng had berthed at Newcastle at 1030 on 16 March 2000 to load a cargo of coal for China. After loading 36 912 tonnes of coal, the vessel sailed at 1144 on 17 March 2000. The draft at sailing was 10.55 m forward, 11.00 m aft.

After departing from Newcastle and disembarking the pilot, normal sea watches were maintained with the autopilot in use. The course recorder, which the master normally used when entering or leaving a port, was switched off after the pilot's departure.

The voyage proceeded without incident.

The 3^rd mate took over the watch at 2000 on 18 March and he and the AB on duty maintained a lookout. The 10 cm radar was in use. At 2020 the 3^rd mate retarded clocks 20 minutes to UTC (Universal Coordinated Time) + 10h 40m.

The ship recorded the following GPS positions,

• at 2200: 27 02.9' S, 153 37.1' E.
• at 2300: 26 51.2' S, 153 36.8' E and,
• at midnight: 26 39.5' S, 153 36.4' E.

The watch was uneventful. When the 3^rd mate handed over to the 2^nd mate, there were no ships or other craft visible at the time. The visibility was in excess of 11 miles and the wind was from the southeast at force 4. There was a slight southeast sea running. There was no rain although the skies were partly cloudy.

The 2^nd mate went to the bridge at 2345 on 18 March, fifteen minutes before the start of his watch as was normal. He and the AB were rested and, when they took the watch, the AB kept a lookout, moving from side to side of the bridge so that there would be no interference with the view ahead. The 2^nd mate used the 10 cm radar to assist with keeping a lookout.

The AB did not see any other vessel ahead of Hai Teng throughout the watch. The 2^nd mate, who was also keeping a lookout, did not recall seeing any other vessel ahead of Hai Teng at the time of the collision as reported by Chester.

At 0047, the 2^nd mate retarded clocks by 20 minutes to UTC +10h 20m. At 0200 he logged a position by GPS, 26 08.5' S, 153 34.9' E and he logged two other GPS positions at 0300 and 0400. Nothing untoward was reported to have occurred during the 2^nd mate's watch.

Chester

Chester sailed from Mooloolaba at about 0700 on 18 March 2000 with the owner and a deckhand on board. When the vessel arrived at the fishing ground at about 0900, the owner used the fish finder to find the best spot to fish. He anchored Chester at about 0930 about 28 nautical miles north east of Mooloolaba Harbour.

While Chester lay at anchor, heading towards the east, in about 78 metres of water, the owner and deckhand fished using rods and lines.

The weather forecast was for showers. There was some rain at about 1600, otherwise the weather was good with about 3/8 cloud cover and good visibility. The wind was mostly from the east, though the owner thought that it might have backed to the northeast during the afternoon.

The anchor light was switched on about an hour after sunset. One of the two low-wattage strip lights on the port side in the well-deck aft was also switched on. At about 2100, the owner went to sleep in the cabin forward of, and below, the wheelhouse.

At that time, the vessel was lying to an easterly wind. There were four other craft in the vicinity that night, one of them a commercial fishing vessel about 3 miles south. There was a boat due north, on the horizon, displaying a white light. There were two other craft, to the southwest and west of Chester.

When the deckhand went to sleep at about 2300, the forward hatch to the cabin was left open for ventilation.

The owner and the deckhand were both asleep when the craft was struck by a ship at about midnight. The sound of the impact was so loud that the owner thought that the fuel tanks might have exploded. He first looked towards the stern but saw nothing, then looked out of the forward hatch and saw the hull of a large ship less than a metre away from the bow of Chester. The ship's hull appeared to be dark grey or black and he thought that he could see draught marks on the side of the ship as it went past, heading north. Contact seemed to have taken place at the ship's port quarter.

The owner was concerned that the anchor rope would be caught in the ship's propeller, pulling his craft into the side of the ship, but the ship passed clear. He checked to see if they were taking on water, lifting hatches set into the deck forward and at the stern, but there were no apparent leaks.

He checked the craft for damage and saw that the fairlead for the moorings and anchor rope was bent though it was still serviceable. There was also a smear of black paint on the starboard rail of the craft.

The deckhand, awakened by the collision and thinking that Chester might have been sinking, went to the wheelhouse where he picked up the handset for the 27 MHz radio. However, he noticed that the owner seemed calm as he checked the craft for damage, so he turned the radio on but did not use it.

When the deckhand learned that there was not much damage to the craft, he went forward to have a look at the ship, but all he could see was its sternlight.

Chester's anchor rope had parted and the craft was drifting. The skipper, after manoeuvring Chester back to the original anchor position, anchored again using a spare anchor.

After a while the owner weighed anchor having decided to return to Mooloolaba. He did not make radio contact with any state authority or attempt to contact any vessels that might have been in the area. At Mooloolaba, the deckhand and he loaded the boat onto a trailer and returned to Brisbane where the deckhand reported the incident to the water police.

Summary

At 0630 on the morning of 9 February 2000, two men launched the 4.5 m fibreglass pleasure craft Sea Wasp, at the Kyeemagh boat ramp in Botany Bay, and headed out to sea for a morning's fishing. The owner of the boat was acting as coxswain with his friend as passenger. Their destination was a fishing place called The Peak approximately 6 miles offshore. The weather was good with north to north-easterly winds at 10-15 knots and a 1-1.5 m swell. The day was also clear with excellent visibility. By approximately 0800 Sea Wasp had arrived at The Peak and the two men were fishing with the boat drifting south. The men had streamed a sea anchor, and the bow of the boat was pointing in a westerly direction. Both men were fishing over the starboard side.

The same morning the crude oil tanker Barents Sea was northbound off the central coast of New South Wales. The vessel was bound for the Shell oil terminal at Gore Bay in Port Jackson. The third mate and master were the only crew on the bridge. They were conducting the navigation and keeping a look-out, the vessel was averaging a speed of 14-15 knots. Both of the vessel's radars were on and set to 6 mile¹ range.

At 0929, Barents Sea altered course, in a position east of Botany Bay, from 015° to 000°. This was the final course alteration approaching the pilot boarding ground off Sydney heads some 10 miles to the north.

At 0934^3/4, Sea Wasp's coxswain was using the boat's 27 MHz radio to contact the local Australian Volunteer Coast Guard radio station to 'check in'. While using the radio he looked up and saw a large ship 50 m away on a collision course. He managed to send a quick 'mayday' signal, at the same time starting the boat's outboard motor. The coxswain turned Sea Wasp to port but, with the sea anchor still streaming, the boat was slow to respond. With the ship 10 m away, and a collision imminent, both men dived out of the boat and into the water.

At 0935, the ship's starboard bow struck Sea Wasp causing structural damage to the starboard side of the boat's cabin, and damage to the windscreen and depth sounder.

The two men surfaced to find themselves on the starboard side of the ship with Sea Wasp still afloat 10 m away and the outboard motor stopped. The men swam to Sea Wasp and re-boarded over the stern. Neither man had sustained injury. They rang 000 on a mobile telephone to request assistance and, during this conversation, identified Barents Sea as the ship they had collided with. The ship had not stopped, and the coxswain used his camera to take some photographs as it steamed away. They then let off an orange smoke flare. Sea Wasp's motor was restarted, and the two fishermen made their way back towards Botany Bay. A Sydney Water Police rescue boat met Sea Wasp 2 miles out from Botany Bay and escorted the boat back to their base at Sans Souci where the coxswain and his friend made statements. The coxswain was breathalysed and found to have a zero-blood alcohol reading.

By 1312, Barents Sea was all fast alongside at Gore Bay. The first indication the crew had of the collision was when the ship's agent arrived on board. They reported that they had seen neither Sea Wasp nor the flare and the ship was found to have sustained no damage.

* Miles referred as nautical mile = 1852 m

Conclusions

Certain aspects of this investigation are unsatisfactory. The fact that there was no match in the paint samples and that a sighting of the flare was not reported by any other vessel or anybody on the land six miles away, must lead to some doubt as to the account of the men on Sea Wasp. However, considering the damage to the boat, the radar, telephone and radio records, the coxswain's photographs and the initial accounts and evidence collected by the Police, the inspector is satisfied that the account offered by the coxswain and his friend is substantially accurate and the collision did occur.

These conclusions identify the different factors contributing to the incident and should not be read as apportioning blame or liability to any particular organisation or individual.

The factors contributing to the collision between the pleasure craft Sea Wasp and the tanker Barents Sea on the morning of 9 February 2000 off Sydney include but are not limited to:

1. There was a lack of an effective visual look-out being maintained by both vessels in the 30 minutes prior to the collision as required by the International Regulations for Preventing Collisions at Sea.
2. Sea Wasp presented as a poor radar target and was consequently not detected on Barents Sea's radar displays by the third mate or master.
3. After Barents Sea changed course at 0929 any radar echo from Sea Wasp would have been at least partially obscured on the ship's radar displays by the electronic heading lines.
4. In the prevailing weather conditions, Sea Wasp's white topsides would have made its visual detection more difficult.
5. The ability of the men aboard Sea Wasp to maintain an effective look-out was hindered listening to the radio.
6. The sea anchor streaming from Sea Wasp's bow limited the manoeuvrability of the boat and the coxswain's ability to take evasive action immediately prior to the collision.