Executive summary

On 1 July 2001, loaded coal train EG37 derailed on Connors Range causing $A21M damage to rolling stock and infrastructure. The accident resulted in the derailment of 75 wagons and 2 electric locomotives and extensive damage to about 500 metres of track and overhead wiring. There were no injuries resulting from the accident.

The investigation into the accident determined that an extended loss of Locotrol radio signal at the top of the range and the failure of the back up safety mechanism in the train brake system triggered the event. The brake system failure was due to a stray O-ring lodged in the seat of the cut off portion of the Brake Pipe Control Valve. The braking of the train was consequently reduced to something less than half its normal capacity. This was insufficient to allow the driver to control the speed of the train down the range.

Queensland Transport acknowledges the efforts of the ATSB for chairing the panel and Queensland Rail for their professionalism and unlimited provision of technical expertise.

Executive summary

An empty suburban electric express train collided with the back of a suburban passenger train at number 4 platform Footscray station just after 0828 on 5 June 2001. The passenger train had about 20 people on board.

The emergency services, including the Police, Fire and Ambulance services attended the scene. As both trains and the rail infrastructure were operated by Bayside Trains, a subsidiary of National Express, the National Express emergency plan was implemented.

The driver of the empty train suffered an injury to his left elbow. Two passengers were taken to hospital for observation but were released with no serious injury.

The evidence available to the investigation suggests strongly that the driver's performance was impaired by a medical condition leading to him being unable to recall events for a period of less than two minutes, between the Maribyrnong River bridge and the point of collision. The driver was taking a course of prescribed medication, which combined with the early start to his working day on the morning of the accident and a history of chronically disturbed sleep, may have resulted in a sleep period (apnoeic episode) while he was driving the train.

There are safeguards or defences to protect against such an eventuality. On this occasion the defences in place failed to prevent the accident. A number of defences were identified as being inadequate in terms of design or application.

The investigation established that the maintenance of the trains was not a factor in this accident. The signalling system and automatic train stop operated within their design criteria. The design criteria of the signal and train stop systems, however, were such that the system could not prevent the collision given the speed of the train involved.

Drivers of suburban trains are required to maintain a given pressure on either a hand or foot pedal 'pilot valve', often referred to as a 'dead-man's handle'. In the event of a driver becoming incapacitated for any reason, the relaxing, or increase of pressure on the pilot valve should automatically apply the train brakes. Examination of relevant literature shows that pilot valves can be intentionally or inadvertently circumvented. In certain circumstances, the foot pedal can be maintained at the correct pressure just by the weight of the lower leg, whether or not the driver is incapacitated. Recommendation 7, below, is made in the full understanding that alternative systems, such as vigilance controls, may not be as effective in a metropolitan rail system, given the density of traffic, the time gap between trains and the workload of train drivers.

The alertness and fitness of drivers to perform their duties is also a defence against accident. While the investigation did not identify any significant defect with driver training, it did find serious defects in the monitoring of driver's health and fitness to operate mass public transport vehicles. The report concludes that the driver of the express train, although experienced and skilled, should not, on medical grounds, have been permitted to drive.

The investigation established that there was a lack of communication and coordination between those responsible for driver management and health professionals. The health standards used to assess driver fitness were themselves deficient.

The report's recommendations are:

1. Medical standards should be reviewed and amended to:

• better monitor drivers' health and ensure a full past history and current medication regime is recorded, including monitor self medication of over-the counter and non prescription medication.
• include an appropriate assessment of the current physiological and psychiatric status of all drivers to ensure operators have all relevant information on which to base an informed decision on driver fitness;
• include a system to identify drivers 'at potential risk', with provision for monitoring ongoing fitness;
• ensure that medical examination periods are strictly adhered to and drivers suspended if not holding current medical license;
• require drivers to produce proof of medical fitness at any time;
• create an audit system that will allow confirmation of compliance with such standards.

1. The medical examination procedures should be reviewed to manage any perception of a conflict of interest in the future medical fitness system and considers whether such examinations should be conducted by a panel of doctors appointed by, and responsible to, the Accreditation Authority.
2. Australian Standard, AS 4292 should be reviewed in respect of the monitoring of the health and fitness of rail safety staff.
3. The signalling system and overlap should be reviewed with a view to ensuring, to the extent practicable, that trains passing a signal at danger are stopped within a safe distance. In sections before a station this distance would ensure a train is brought to a halt before a possible collision with another train stopped at the station.
4. The anti-collision posts on motor cars on Com Eng trains should be further investigated to identify any deficiency in their design.
5. Rail accident response plans should be reviewed to provide procedures to ensure immediate safety of the track infrastructure, training for station staff at manned stations in immediate response procedures and rapid deployment of staff at unmanned stations.
6. The use of hand and foot pilot valves should be reviewed, given their limitations, to determine whether the system can be made more effective or whether an alternative, equivalent system might make a better safeguard.
7. The train system radio network should be reassessed for radio reliability.

Copies of the report are available from the Victorian Department of Infrastructure's Customer Service Centre, Plaza Level, 80 Collins Street, Melbourne or by telephoning (03) 9655 8830.

Executive summary

At 0743 on 25 April 2001, the Countrylink XPT daylight service ST3 (train 8622) left Sydney bound for Melbourne. The train consisted of a lead power car followed by seven passenger cars designated from 'A' through to 'G' and a trailing power car. On board the train was a crew of five- the driver, a passenger service supervisor and three passenger attendants- and 127 passengers.

The run from Sydney south was routine. No problems were reported at the driver changeover in Junee at approximately 1354. At 1528 the train arrived in Albury where the passenger service supervisor and three passenger service attendants changed over. The train departed from Albury Station at 1532, approximately 30 minutes late, with 98 passengers on board.

After leaving Albury Station, the driver accelerated to 80 km/h and maintained that speed until approaching the Melbourne end of the Wodonga coal sidings, where he reduced the train speed to slightly below the 40 km/h posted speed. Shortly after this, the train passed the Hovell Street level crossing in Wodonga and continued to round the tight right-hand curve in the main line before the High Street level crossing. The train's speed was approximately 25 km/h. As the train entered this section of curve, the driver applied some power to maintain the train's speed through the curve.

At approximately 1538 at 301.1086 km, the inner wheel on the lead axle of the lead bogie (NHA 198B) of car 'E' (XF 2214) dropped from the low rail of the curve. At 301.105 km the inner wheel dropped completely from the low rail into the track fourfoot. The train travelled approximately 2.75 m further until the outer wheel on the same axle climbed over the high rail and onto the ballast shoulder on the outside of the curve. At 301.0911 km the trailing wheel-set of the bogie also derailed with the outer wheel climbing over the high rail and the inner wheel simultaneously dropping into the four-foot. The bogie, now completely derailed, travelled in this condition for approximately 950 m until the train was brought to a stop by the driver. The driver had stopped the train in response to a passenger emergency alarm which had been initiated by the passengers in car E.

The derailment occurred on the sharpest curve on the main line between Sydney and Melbourne. The alignment at this point in the main line was originally dictated by the presence of a crossing diamond where the broad gauge branch line to Bandiana had crossed the standard gauge main line. The alignment of the curve had not been changed since the closure of the branch line and the removal of the diamond in 1997.

Assessment of the track at the derailment site revealed a number of factors which contributed to the derailment, the most significant of which was the condition of the high rail fasteners which resulted in gauge widening of up to 49 mm at the point of derailment.

The derailment was unusual in some ways as there had been other freight and passenger train traffic on the line earlier in the day without incident. In addition, the derailment involved only one bogie in the middle of the train with bogies in the same train passing safely over the site before and after bogie NHA 198B had derailed. This indicates, that while the track-based elements were the primary causal factors, it was the combination of the vehicle-based and track-based factors that caused the derailment.

Inspection of the bogie which derailed revealed some factors which contributed to the derailment including a thin flange on the number-1 wheel and the poor condition of the bogie's side bearer yaw friction pads.

Summary

At 1915 on 11 October 2001 the Panama flag bulk carrier Cape Kestrel, in ballast, anchored off the port of Dampier, Western Australia, waiting for a berth to load a cargo of iron ore for China. The next morning, the master decided to conduct a lifeboat drill and to lower the port lifeboat to the sea. Since the vessel was to berth port side to the ore loader, his intention was to also lower the starboard boat while alongside.

At about 0845, the boat, with the mate and four crewmembers on board, was lowered to the water where the hooks were disengaged. The release mechanism for the boat was checked and the engine was run ahead and astern. When the hooks were reconnected, a seaman on deck operated the remote control to recover the boat.

The remote control, however, did not start the winch motor, and the mate asked the first engineer, who was on deck at the time, to hoist the boat. The first engineer went to the starter panel for the lifeboat winches, located in the air conditioning room aft in the accommodation, and started the winch by manually depressing the main contactor for the motor.

Hoisting was stopped at the main deck, where the master, who had been watching from the bridge wing, ordered the mate to arrange for the occupants of the boat to disembark before swinging the boat in. The mate replied that the boat was too far from the deck for people to disembark safely and that it could be hoisted to the boarding platform with its crew on board.

Despite the master's protests, hoisting of the boat resumed with the first engineer depressing the contactor in the starter panel. The davits came in, past the limit switches and up against the stops, with the winch still running. The forward fall parted, followed by the after fall, causing the boat to fall about 20 metres to the water. Four crew members in the boat were injured, three of them seriously.

The mate's injuries were the most serious and he was taken ashore by pilot boat. He was examined at the hospital at Karratha and transferred to a hospital in Perth for treatment.

Three other crewmembers in the boat were taken ashore by helicopter for treatment at the hospital at Karratha. Two of them were repatriated after treatment, while the remaining crewmember rejoined the ship before it sailed. The bosun, who had also been in the boat, suffered only bruising to his forehead.

The boat was later recovered. New falls were fitted to the davits and cracks in the boat were repaired. Broken windows were scheduled for repair at the earliest opportunity.

The Panama Maritime Authority authorised the vessel to sail for a period of 30 days until 12 November 2001 while repairs to the boat were arranged, provided that liferafts of the same capacity were provided on board. Before the vessel sailed from Dampier, a suitable liferaft was fitted on board.

Summary

At about 0200 on Saturday 17 November 2001, the Hong Kong registered bulk carrier Nego Kim arrived at the port of Dampier and anchored to await berthing instructions. The ship, which was on a time charter to load a cargo of scrap iron at Fremantle, Adelaide and Dampier, for discharge in Singapore, remained at anchor through Saturday and Sunday. At anchor, the crew continued tasks from the ship's planned maintenance schedule, including the preparation of the interior of no.1 port topside ballast tank for painting.

On Sunday morning the crew performed some routine cleaning tasks. At about 1300, the mate monitored no.1 port topside ballast tank for oxygen content in accordance with safe entry procedures. At about 1430, the eight-man deck crew started work painting the steelwork inside the tank. One man was engaged in painting with an airless spray gun while the other deck crew maintained the paint reservoir, tended a cargo light lowered through the after manhole and assisted the painter as required. An open-ended compressed air hose was led from the forecastle, along the deck and down through this after manhole, while an electrically driven fan was positioned at an angle over the after manhole, which also provided access for the paint hose, light cable and a lanyard.

The mate supervised the initial stages of the task. The paint used was a two-part epoxy mix, thinned as needed using the thinner product supplied by the paint manufacturer. According to the mate, the volume of thinner used was between 30 and 50 per cent of the total mixture.

At about 1530 the mate went to the bridge to start his 1600 to 2000 anchor watch, leaving the bosun and deck fitter in charge at the site.

At about 1640 a large explosion ripped through the tank. The tank ruptured and three men were blown down the length of the main deck, killing them all instantly. The explosion also blew four other men over the ship's side. One man, who had been inside the tank, was still alive although severely burned. He was assisted out of the tank, through the ruptured main deck plating, and later airlifted ashore. Eighteen days later he died in hospital as a result of his burns and other injuries.

A search and rescue operation was initiated, using various surface vessels and aircraft as they became available, in the hope of finding the four men who had been blown overboard. The body of one of the men was recovered from the water at about 1325 the next day, 19 November. The search was continued until last light on 21 November, but none of the other three crew were found.

The report recommends safety actions to improve the ISM documentation carried on ships to include clear instructions for all operations in enclosed spaces and guidance on the conditions under which work in enclosed spaces should be undertaken. Recommended safety actions are also directed to the Dampier Port Authority with regard to an emergency response plan.

Captain Aysuna

Captain Aysuna is a 5-hatch, geared, Panama flag bulk carrier. The vessel, built at the Usuki Iron Works Ltd in Saiki, Japan in 1985, is classed with Nippon Kaiji Kyokai. It is owned by Hydale Trading Corporation and, at the time of the incident, was on time charter to BHP Transport and Logistics Pty Ltd.

The vessel has a length overall of 168 m, a beam of 27 m and a depth of 13.45 m. It has a gross tonnage of 16 080 and a summer deadweight of 26 914 tonnes at a draft of 9.547 m. Captain Aysuna is powered by a Mitsubishi 6 UEC52LA slow speed diesel engine delivering 5 279 kW to a single, fixed pitch, propeller, giving the vessel a service speed of 13.5 knots.

The vessel had a crew of 24, comprising 19 Bulgarian and two Indian nationals, a Russian, a Yugoslav and a Turk.

Conclusions

There was a definite and concerted attempt by members of the crew not to cooperate with the investigation. The area affected by the fire was cleaned and painted over in an attempt to hide all evidence of the cause of the fire, and, while the crew almost certainly knew what had caused the fire, they did not divulge this information to the ATSB.

It is probable that the fire was caused by spillage of a small amount of fuel from a container left at the forward edge of the boiler flat. The fuel, probably being used as a cleaning medium, could have spilled as a result of movement of the ship in rough seas. It is likely that this fuel was diesel oil.

The fire, while it produced a quantity of flame and smoke, only caused minor paint damage and did not cause any damage to machinery.

Summary

At 2100 on Monday, 6 August, the small general cargo vessel ANL Purpose was at the position 18 23.6' S, 152 54.3' E making good 11 knots on a course of 174 (T) on passage from Lae, New Guinea, to Melbourne. The weather was fine. The nearest land was Marion Reef, 45 nautical miles to the southwest and Lihou Reef, some 76 nautical miles to the northwest. The master was on watch on the bridge and the chief engineer was in his cabin, when an engine alarm annunciated.

Upon investigating, the chief engineer heard loud noises coming from the main engine, which he promptly stopped. After opening the port crankcase door on no. 4 unit, he saw that both the piston and the cylinder liner had shattered into numerous small pieces and the engine sump was full of debris. There was also significant damage to the engine block. The chief engineer realised that it would not be possible for the ship's staff to carry out repairs sufficient to restart the main engine, even on five cylinders and, at 2215, he advised the Master accordingly.

The master informed the vessel's owner and AusSAR (the Australian Search and Rescue Co-ordination Centre) of the vessel's predicament. ANL Purpose was drifting, in a mainly north-westerly direction, at a speed of approximately 1.3 knots. It was, however, in no immediate danger.

At 1654 on 8 August, the Townsville-based tug Giru made a rendezvous with ANL Purpose which had, by that time, drifted to a position of 1759.1' S, 15215.1' E, and passed a tow to the ship. The tow, at a speed of 7 to 71/2knots, proceeded towards Brisbane in good weather with light south-easterly winds.

On 10 August, in the shelter of Saumarez Reef, the tow was taken over by the Brisbane-based tug Bulimba. The good weather held for the remainder of the tow to Brisbane and, on 12 August, ANL Purpose arrived at the repair wharf of Forgacs Cairncross shipyard in the Brisbane River.

The investigation concluded that:

• The proximate cause of the failure was the partial seizure and consequent break-up of the piston in no. 4 unit. The partial seizure was brought on by an obstruction to piston cooling oil flow caused by the axial movement of the bottom-end bearing shells, which may have been incorrectly fitted.
• The piston in no.4 unit was suffering from significant fatigue cracking, as were those in nos.1 and 2 units, and the additional loading from the partial seizure was sufficient to cause the break-up of the piston.
• The pistons were those originally fitted sixteen years earlier and there was no evidence that they had ever been replaced or crack-detected during that time. The engine manufacturers had issued service bulletins relating to the maintenance and crack detecting of the later two-piece type of pistons, but not for the original, one-piece type.
• The standard of maintenance records kept aboard the vessel was less than adequate.

The report recommends that the engine manufacturer consider issuing a service bulletin covering the crack-detecting of any of the earlier, one-piece, pistons which may still be in service.

Conclusions

• The ANL Purpose main engine failure occurred due to the partial seizure and consequent fracture and break-up of the piston from the number-four cylinder assembly.
• First indication of engine failure was the detection of elevated crankcase oil mist levels due to increased friction within the cylinder.
• The presence of pre-existing fatigue cracking within the body of the number-four piston had contributed to the failure.
• Two other pistons from the engine were also cracked in a similar manner.
• In-service cracking of the pistons was a known design issue and the engine manufacturer had published enhanced inspection requirements for pistons that have accrued more that 24,000 operating hours. A later service letter published service time limits for the main components of the VASA 32 engines. At the time of the failure, the pistons from the ANL Purpose had a service time well in excess of the published limits for piston replacement.
• The connecting rod big end bearing shells had migrated forward of their normal positions and had sustained damage as a result of contact with the crankshaft journal radius.
• Movement of the bearing shells had partially obstructed the oil flow pathway between crankshaft and connecting rod / piston. At a constant feed pressure, this would reduce the total volume of oil flowing through the number-four assembly.
• Control of the piston crown operating temperatures requires that a positive flow of oil be maintained. Any reduction of oil flow volume would be expected to result in an increase in piston temperatures.
• An increase in piston temperatures will result in the physical expansion of the piston body, reducing the bore clearances and increasing the risk of binding and seizure. Evidence of binding and partial seizure was found on fragments of the piston skirt and cylinder bore from the failed engine, although it could not be ascertained at what stage of the failure the damage was sustained.
• Binding within the cylinder bores will elevate the loads being transmitted through the piston body. Under these conditions, the presence of cracking or other defects may predispose the component to failure in the manner observed within the main engine of ANL Purpose.

Summary

At 1100 on 7 August 2001, the Hong Kong flag container vessel Maersk Tacoma departed Melbourne en route to Brisbane. The ship was loaded with containers and had a mean departure draught of 11.10 m. By 1524, the ship had cleared Port Phillip Bay, and was running at sea speed heading eastward through Bass Strait.

Between 1608 and 2200 on 7 August, the main engine was stopped four times in response to low Lubricating Oil (L.O.) alarms. After the stoppage at 2200, the engineers inspected the main engine crankcase and found that number twelve bottom end bearing had failed. The fuel to number twelve cylinder was turned off and the main engine was restarted at 0114 on 8 August. The intention was to proceed at reduced speed to a safe anchorage where the damage to the main engine could be better assessed.

At 0152 the main engine was stopped again after another low L.O. pressure alarm. The chief engineer found that he was having difficulty maintaining the lube pressure and informed the master that he could not use the main engine. The master then contacted the ship's managers in Hong Kong to inform them of the situation. Maersk Tacoma was approximately 13 nautical miles west of Rodondo Island and, with the wind from the north-west at force five, started drifting southeast at 2.5 knots.

By 0500 the weather had deteriorated with the wind force seven from the northwest and the vessel's rate of drift had increased to 3.0 knots in an easterly direction.

During the next four hours the weather continued to deteriorate as the ship drifted towards Cutter Rock which has a charted depth of 7.4 m. By 0900 the distance to Cutter Rock had closed to 1.8 miles on a bearing of approximately 135(T). The master was very concerned that the ship would ground on Cutter Rock and asked the chief engineer if he could have the main engine again for what ever time was possible. At 0910 the main engine was started dead slow ahead with one of the engineers controlling the main engine from the engine side control stand as the remote control system was unserviceable. At 0928 the main engine was stopped again after another low L.O. pressure alarm but in the 18 minutes that the engine had run the ship had tracked far enough north to clear Cutter Rock by 0.8 miles.

At 0946, the Rescue Coordination Centre (RCC) in Canberra was contacted by the ship's charterers who reported Maersk Tacoma's situation.

At 1026 the starboard anchor was lowered in an attempt to slow the ship's rate of drift. A short time later it was apparent that Maersk Tacoma's drift had slowed to 2.5 knots but the ship was now drifting east-north-east towards the Hogan group of islands some 16 miles away. The master was now concerned about the possibility that the ship would ground on one of the Hogan islands. Two attempts by the crew to raise the anchor after this time were unsuccessful.

Maersk Tacoma was contacted by Swire Pacific Offshore at 1225. They indicated that the salvage vessel Pacific Conqueror had departed from Barry Beach and would take approximately four hours to arrive at the ship's position. The master was still concerned that Maersk Tacoma would ground on one of the Hogan islands before Pacific Conqueror arrived to take the ship under tow. The RCC was also concerned and made arrangements for two helicopters to stand-by on Hogan Island if it became necessary to evacuate the ship's crew.

At 1505 Maersk Tacoma was six miles from Hogan Island when the main engine was started again in an attempt to save the ship despite the certain knowledge that the main engine would be damaged further. At 1618 the engine was stopped with Maersk Tacoma 4.3 miles north-west of Hogan Island and out of immediate danger.

Pacific Conqueror was sighted on the starboard beam by the crew of Maersk Tacoma at 1646 and was alongside the ship by 1706. By 1822 Pacific Conqueror had taken the ship in tow by hooking the ship's anchor cable using a 'J' hook. The tow then proceeded without significant incident until 1300 on 9 August when the two vessels arrived at a safe anchorage off Sealers Cove on the eastern side of Wilson's Promontory.

By 12 August the weather had moderated sufficiently to allow Maersk Tacoma to be towed to Melbourne. On 14 August, the ship arrived at Swanson Dock where it remained until 17 October 2001 while damage to the main engine was repaired.

The report's conclusions include:

• The ship's main engine was disabled when number twelve bottom end bearing failed.
• It is likely that the bottom end bearing failure was the result of its pre-existing condition in combination with reduced L.O. flow.
• Maersk Tacoma's engineers placed themselves in significant danger by running the damaged main engine to save the ship on two occasions when it was at risk of grounding on both Cutter Rock and the Hogan group of islands.
• Maersk Tacoma's crew were unnecessarily imperilled by the failure to notify Australian authorities of the vessel's situation for some eight hours after the main engine was found to be effectively unserviceable.
• The delay in notifying the Australian authorities of the breakdown and the potential risk to the environment, together with the time taken to organise a tow indicates significant deficiencies in the ship manager's emergency planning.

The report recommends that:

Ship owners and operators include procedures in their vessel's safety management systems which stipulate that local rescue coordination centres must be notified promptly if the ship becomes disabled.

Summary

On 27 June 2001, the multi-purpose cargo vessel Mirande berthed at Geelong to load a cargo of barley. Whilst alongside, an AMSA surveyor on board for an inspection, formed the opinion that the master and chief engineer were under the influence of alcohol and formally advised them to cease drinking so that they would be fit at sailing time.

When the pilot boarded for departure, the ship's chief engineer came to the bridge and whilst not claiming to be the master, he did not deny it when addressed as 'captain'.

During the outward passage, as the ship passed to the south of beacon 12 in the South Channel, the ship's steering gear suffered a telemotor system failure. None of the bridge team, however, attempted to change to the other system or attempted to use the non-follow-up (NFU) steering controls. The ship's momentum and the proximity of the edge of the channel, however, resulted in the ship grounding within a few minutes.

After the grounding, the pilot asked for the master to return to the bridge but to no avail. Eventually the pilot was told that the master was 'drunk'. The water police were called and arrived on board at 0020 on 29 June 2001. They performed preliminary breath tests on the pilot and the first, second and third mates. The results of all these tests were negative. The police officer then went below and tested the master and chief engineer. The master's alcohol reading was 0.29 g/100 ml and that of the chief engineer was 0.13 g/100 ml.

The report conclusions include:

• Two fuses in the primary side of the transformer supplying power to the port telemotor system blew, causing failure of the hand steering in use at the time.
• The mate and third mate had inadequate knowledge of the bridge equipment, particularly the emergency steering change-over procedures.
• The helmsman had received no training in emergency steering procedures.
• Intoxication of the master resulted in his absence from the bridge at the time of the steering failure and hence in a lack of proper leadership, experience and knowledge at a time when it was particularly needed.

The report makes recommendations to:

• The Australian Maritime Safety Authority should seek legislation to allow suitably trained AMSA marine surveyors, where there are reasonable grounds to do so, to measure blood alcohol levels of ship's crews using breath analysis equipment. A positive test of a master or key operational crew should provide grounds for detaining the vessel. AMSA should also advise the relevant harbour master or marine authority of the situation.
• Ship's officers should ensure that they (and any appropriate seamen) are familiar with the emergency operation of all ship's equipment.

Conclusions

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

Based on the evidence available, the following factors are considered to have contributed to the grounding:

1. For a reason which could not be determined, two fuses in the primary side of the transformer supplying power to the port telemotor system blew, causing failure of the hand steering in use at the time.
2. Fuses of the 'instantaneous' rather than the 'slow blow' type had been fitted.
3. The mate and third mate had inadequate knowledge of the bridge equipment, particularly the emergency steering change-over procedures.
4. The helmsman had received no training in emergency steering procedures.

Additionally, but not directly:

1. Intoxication of the master resulted in his absence from the bridge at the time of the steering failure and hence in a lack of proper leadership, experience and knowledge at a time when it was particularly needed.
2. The pilot was licensed only to 9.5 m maximum draught; however the draught was 10.05 m and he had obtained a verbal exemption from his managing director to undertake this passage. He had been advised that the sailing draught would be 9.5 m by the ship's agent.

Summary

The British flag passenger ship Regal Princess arrived off the Queensland port of Cairns at about 0530 on 15 March 2001 and embarked a pilot to conduct the vessel for the inward passage. The weather was clear with a wind from the south-east at 15 to 20 knots at the pilot boarding ground.

Some difficulties were experienced with the handling of the vessel during the inward pilotage due to the windage of the ship and its manoeuvring characteristics. The ship swung in the turning basin and made fast port-side-to its assigned berth at about 0645. There was some minor damage sustained by the harbour tug through contact with Regal Princess during the berthing operation.

Sailing time was set as 1700 the same day.

At 1500 that day, a meeting was convened between the harbour master, the pilot, duty pilot, the ship's agent and the master of Regal Princess to discuss the departure. The pilot who conducted the inward pilotage was also assigned for the outward pilotage. He was concerned about both the height and ebb of the tide at the scheduled departure time of 1700. Together with a strong wind warning, these would combine to increase the difficulties in handling the ship.

The outcome of the meeting was that the sailing time was amended from 1700 to 0200 the next morning, 16 March 2001. At that time the wind was expected to have abated, the tide would be flooding and there would be a greater under keel clearance (UKC).

At 0200 the vessel left her berth and proceeded outward. The wind was still from the south-east, at about 8 knots at the berth, increasing to 15 knots outside. The departure proceeded as expected until the ship reached the vicinity of beacon C14, when a series of pronounced yaws developed, culminating in the vessel grounding and coming to a stop at 0240 on the eastern side of the channel, with its starboard shoulder between beacons C14 and C12. The ship was aground for about 4 minutes. The ship was then manoeuvred off the bank and proceeded out to the anchorage.

Nobody was hurt as a result of the grounding and there was no pollution. The ship was checked internally for damage and found to be sound and seaworthy. As the sea state and current in Cairns prevented an inspection by divers at that time, the ship was released to proceed onward to Darwin. The underwater inspection in Darwin, the next port, revealed minor hull damage with a small area of the bottom plating having been set up under the bulbous bow, which was likely to be partly the result of an earlier grounding in the Carribean.