Summary

Late on the evening of 10 June 1997, the Egyptian bulk carrier Thebes, on a ballast passage from Singapore to Newcastle, NSW, embarked a licensed coastal pilot to the north-west of Booby Island for the passage through Torres Strait and the Inner Two-way Route of the Great Barrier Reef.

At about 2345, after negotiating Gannet Passage and with the vessel steadied on a course with Goods Island light right ahead, steering was changed from manual to automatic steering mode. The Pilot then handed the con back to the Master, in order to go below for a few minutes, but before leaving the bridge, at about 2352, he explained his passage plan, on the chart, for the Torres Strait.

When the Pilot returned to the bridge at 0002, the Master and watch officers were at the chart table. Moving through to the wheelhouse, the Pilot initially could not see Goods Island light ahead, but seeing the heading was on 110, he then saw the light wide on the port bow. At the same time, the Master's attention was brought to the 2400 position on the chart, which was well to the south of the track. The Master ran to the steering console and the rudder was put hard to port. However, after turning through about 70, Thebes ran aground on the south side of Larpent Bank.

The engine was put to full astern, water ballast was dumped from the forward upper wing tanks and pumped from the forepeak, and the vessel refloated at 0112 on 11 June. Soundings indicated that no tanks had been breached, therefore passage was resumed.

No pollution or significant damage to the vessel occurred as a result of the grounding and no-one was injured.

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. Thebes grounded after it had deviated from the intended course, the deviation going unnoticed by the ship's bridge team for a period of almost 15 minutes. The following factors are considered to have contributed to the grounding:

1. An error in the setting of the selector switch when changing from manual to autopilot steering modes.
2. During the period the Master had the conduct of the vessel, while the Pilot was absent from the bridge, all officers remained in the chart area and the vessel's progress was not monitored.
3. The spontaneous and simultaneous reactions of the Master and the Pilot to go hard to port, towards the intended track, before a full appraisal of the situation was carried out.
4. The lack of Bridge Resource Management procedures on board, which resulted in the wheelhouse being unattended, the vessel's progress not being monitored and the order to go hard to port not being challenged by the Officer of the Watch.
5. The design of the steering console is such that the setting of the selector switch is not readily discernible, particularly to someone of medium or small stature and at night cannot be readily seen at all. It is further considered that it was reasonable for the pilot to have absented himself from the bridge at that particular time.

Summary

On 12 July 1997, the Indian flag bulk carrier Dakshineshwar was on a loaded, northbound passage through the inner route of the Great Barrier Reef, from Hay Point to the east coast of India with a cargo of coal. A licensed Reef Pilot was in charge of the navigation.

At about 2100, the vessel passed between Alert Patches and OG Rock at the eastern end of the Prince of Wales Channel, Torres Strait, and settled on a course of about 270. The ship's speed over the previous hour had been 12 knots.

At about 2111, the vessel was abeam of Ince Point and the Pilot saw that the Global Positioning System display showed a speed of 10.5 knots. About three minutes later the Pilot, who had moved to the port bridge wing, heard an alarm or some alerting device ringing on the bridge, and he went to investigate. As he got close to the centre line, he glanced at the helm indicator and engine room tachometer. The helm indicator showed that full starboard rudder had been applied and the tachometer showed zero revolutions. The ship's head had been paying off to port and the rate of turn increased rapidly as the ship closed with Wednesday Island to the western side of Ince Point.

The ship's speed had slowed to about 6.5 knots when the engine was restarted. The Pilot had to make a quick decision and decided to maintain full starboard rudder and ordered emergency full ahead revolutions to maximise the rate of turn to starboard. The ship reached a heading of 172, before starting to turn to starboard. At about 2120, Dakshineshwar grounded in position 10 30.4 degrees South 142 17.9 degrees East, with Ince Point Light bearing 100 x 0.85 of a mile.

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. The following factors are considered to have contributed to the grounding:

1. The engine failure which occurred sometime after 2100.
2. Too rapid shut-down of the freshwater generator.
3. The practice of manually adjusting the set point on the jacket cooling water temperature controller.
4. The lack of understanding and knowledge of the proper operation of automated systems and specifically the engine temperature control system by all the engineers.
5. The lack of sufficiently experienced engineers in the engine room while preparing for stand-by.
6. Poor or deficient operational procedures in the MCR.
7. Deficient communications between the bridge and engine room and the failure to use the most basic communication system, the bridge telegraph. It is further considered that.
8. The Pilot had to make an immediate decision and took the best action under the circumstances.
9. The assumption made by the 3rd Mate that the problem was not the engine but the steering, and any confusion that caused, occurred at such a time that his actions did not alter the outcome.

Summary

The 30,396-tonne deadweight Panamanian flag bulk carrier Western Winner sailed from Singapore on 27 April 1997, bound for the east coast of Australia, by way of Torres Strait. The vessel had been chartered by the Australian Wheat Board to load a cargo of grain for Egypt.

Within 24 hours, on the morning of 28 April, the ship's destination was changed, and the vessel was directed to Port Adelaide. The Master altered the vessel's voyage plan and set course by way of the west coast of Australia and the Great Australian Bight.

On 6 May, after the vessel had rounded Cape Leeuwin, the ship's orders were changed again and the ship diverted to Wallaroo in the Spencer Gulf, before calling at Port Adelaide. Western Winner did not carry all the necessary charts, lacking two and in particular chart Aus 777, "Winceby Island to Point Riley", which covered Tiparra Reef and the approaches to Wallaroo. The Master telexed the ship's agent requesting that he supply the two charts on arrival at Wallaroo.

The position of the pilot boarding ground off Wallaroo was taken from publications carried on board and marked on a sheet of blank paper fixed to the chart covering the northern area of the Gulf. The ship's course was laid off directly for the pilot boarding ground.

On the afternoon of 8 May, Western Winner entered Spencer Gulf. The ship continued on passage, expecting to arrive at the Pilot ground at about 2230. After dark, the ship experienced rain squalls and restricted visibility.

At about 2130, the radar showed an echo fine to starboard. In view of the heavy rain, the Master put the engine on standby and reduced speed. At about 2210, the ship ran aground with Tiparra Reef light bearing 128x 1.2 miles in position 34 03.2' South 137 03.2" East.

Ballast was jettisoned and at about 1345 on 9 May, the vessel refloated without assistance and, under its own power, cleared the reef and proceeded to the anchorage off Wallaroo, dropping anchor at 1530.

No injuries were incurred by any of the crew and no pollution resulted from the grounding.

Conclusions

These conclusions identify the different factors contributing to the incident and should not be read as apportioning liability or blame to any particular individual or organisation. The following factors are considered to have contributed to the grounding of Western Winner on Tiparra Reef on 8 May 1997:

• The absence of the appropriate charts for the approaches to Tiparra Reef and Wallaroo.
• The failure to refer to the Admiralty sailing directions for a description of the waters of Spencer Gulf.
• The Master not informing the owners of the absence of the chart on 6 May.
• An unwarranted assumption by the Master that the ship's agent would have been alerted to the absence of appropriate charts, merely because he requested charts be supplied on arrival, and he would have been informed of any hazard on the passage.
• The change in orders from Port Adelaide to Wallaroo as first port.
• A lack of compatible records between the ship and shore management as they related to the chart folios carried on board Western Winner.

Summary

At 0600 on the morning of 6 May 1997, the Panamanian flag woodchip carrier Taio Frontier arrived at the pilot boarding ground off the entrance to the Tamar River, Northern Tasmania, to embark a pilot to proceed to Bell Bay. Due to a north-easterly swell, the two pilots assigned the job were unable to get to the pilot ladder, rigged on the port side, and they requested the Master to go full ahead and hard to starboard, in order to make a lee.

The Master ordered hard to starboard, but because of concern about the closeness of Hebe Reef, only ordered slow ahead. As soon as both pilots were on board, he ordered full ahead and hard to port, then instructed the helmsman to steady on 160. On gaining the bridge, the first pilot realised the ship was headed for West Reef and ordered full ahead, hard to port.

When the ship had swung to a heading of about 102, there was a shudder as though the ship had struck the bottom, but the ship maintained its forward movement. Speed was reduced to half ahead and the pilot took the ship to anchor, close to the pilot boarding ground, where all tanks were checked, and machinery and controls tested. Everything appeared normal and there was no ingress of water or sign of oil pollution, therefore the pilotage was resumed.

From the estimated position of the contact, the charted depth was around 16 m to 17 m, with a rise of tide of one metre, while the draught aft was 7.72 m. Subsequent inspection by divers revealed the tips of two adjacent propeller blades had been damaged and the heel of the rudder set upwards, indicating contact with an obstruction of relatively small area.

Conclusions

These conclusions identify the factors contributing to the incident and should not be taken as apportioning either blame of liability. The main contributing factors are considered to be:

• The pilot ladder was rigged on the weather side, preventing the Pilots from boarding until a lee had been provided.
• The lack of any planning of the approach, with no delineation of danger areas or safety limits on the chart, or consideration of possible contingencies.
• A misunderstanding on the part of the Master of what the Pilot requested regarding the making of a lee.
• Inappropriate action to provide the necessary lee to enable the Pilots to board.
• The lack of Bridge Resource Management procedures, in that the Master did not inform the Mate of his intended actions or seek the Mate's support in monitoring and advising him on the progress of the manoeuvres; in that the Mate did not provide active support to the Master; and in that navigational equipment was either ignored or not used to full effect.
• The differing ethnic/cultural backgrounds of the Master and the deck officers, which inhibited the Master in his dealings with those officers.

Summary

Early on 25 April 1997, the Australian steel hulled, long-line fishing vessel Exterminator was repositioning to the south, before shooting its line, about 19 miles east by south of Green Point, New South Wales. The Skipper was on watch in the wheelhouse and had noticed, on the radar, a vessel coming up from astern, shaping to pass clear on the port side.

Suddenly, at about 0040, there was a loud bang and a jolt, and the Skipper was thrown to the deck on the port side of the wheelhouse as Exterminator rolled heavily to port. Pulling himself back to a standing position, the Skipper saw the hull of a large vessel, in a light condition, passing up the fishing vessel's starboard side. As Exterminator rocked as a result of the initial collision, it came into contact twice more with the hull of the other vessel.

The Skipper put out a number of calls on VHF16 but received no response. He reported the collision to AMSA, then, after contacting the owner, returned to Eden to assess the damage.

The 110,461 tonnes deadweight Liberian tanker Unisina had sailed, in ballast, from Gore Bay, Sydney, on the morning of 24 April 1997, bound for the FPSO Cossack Pioneer, located on the Northwest Shelf.

At midnight on 24 April, the vessel was in a position 20.5 miles east of Green Cape, making good a speed of 11.6 knots on a course of 196. Shortly after 0030, the officer of the watch started altering course slowly to starboard for a vessel, which he considered to be northbound and crossing from starboard to port. After about five minutes and with the ship heading about 235, the officer applied hard to starboard rudder, then port rudder, in an apparent attempt to avoid a collision.

Scientific comparison by the Australian Federal Police Scientific Branch matched paint taken from the hull of Unisina with paint deposited on Exterminator, indicating that Unisina was the vessel that collided with the fishing vessel.

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.

Unisina collided with Exterminator after the Watch Officer mistook the lights of Exterminator to be those of a more distant, crossing vessel and altered course towards the fishing vessel. The following factors are considered to have contributed to the incident:

• A proper lookout was not maintained on the bridge of Unisina between midnight and 0030.
• A proper appraisal of the situation was not carried out by the Watch Officer, by using either visual bearings or radar, before he altered course to starboard.
• Reduced alertness on the part of the Watch Officer, brought about by a sleep debt and 'jet lag'.
• The absence of any guidelines to owners and operators by the Flag Administration, or instructions to masters by the vessel's operator, on rest period requirements to overcome the effects of long-distance travel prior to joining a vessel.
• A proper lookout was not maintained on Exterminator.
• The inappropriate display of fishing signal lights by Exterminator.

The investigation was discontinued.

Summary

On 8 March 1997, the Australian tanker Osco Star was in the southern Coral Sea south of Lihou Reefs, on a loaded passage from Geelong to Port Moresby. The vessel had been experiencing east-south-easterly gale force winds since passing Fraser Island on the evening of 6 March.

To the north of Lihou Reef, a tropical depression, moving slowly in a south-westerly direction, had been developing to cyclone status and had been allotted the name 'Justin'.

During the early evening of 8 March, Osco Star experienced a gradual decrease in the wind to force 2, then the wind backed to the east-north-east and increased in strength, indicating the vessel had passed close eastwards of the cyclone's centre. By late evening the wind had shifted to the north-north-west, at gale force, and the engine speed was reduced due to the heavy weather.

Towards daybreak on 9 March, the wind increased to storm force. At 0620, an earth fault alarm in the engine control room led to the eventual discovery that seawater had entered the emergency generator room, located on the port side of the poop deck, and was sloshing up underneath the emergency switchboard.

During attempts to rectify electrical faults in the emergency generator room, fuses were removed in the 24-volt rectifier/charger unit, inadvertently stopping all engine room pumps. The main engine, however, continued to run, and only stopped once the fuses had been replaced nearly two minutes later. At about 0841, as the fuses were replaced, there was a complete loss of electrical power.

The main engine was restarted from the emergency manoeuvring position at 0925, but short circuits had damaged the 220-volt section of the emergency switchboard, causing the loss of some engine room instrumentation. Seawater had also caused the failure of the 24-volt rectifier/charger unit. The 24-volt system had switched to battery back-up and the batteries were discharging. By about 1100, the battery voltage had fallen to the point where the contactors in the pumps automation system started to drop out. The main lube oil pump stopped, the stand- by pump failed to start and the engine continued to run until, following some confusion, it was manually stopped by the Chief Engineer.

After carrying out checks on the engine it was restarted but, at 1248, was again stopped for a brief crankcase inspection after loud metallic banging was heard as speed was increased. Nothing was found amiss during the inspection. After again getting under way, there were more noises from the engine and it was noticed, later that afternoon, that the crankshaft had moved about 25 mm forward.

That evening, debris from the crankcase, including paint flakes, white metal, shards of steel and brass shims started to block the lubricating oil strainers which required cleaning at 11-minute intervals.

The ship was nursed to Brisbane where, upon opening up the main engine, it was found that the ahead pads in the thrust bearing had been dislodged, and the crankshaft had moved at least 30 mm forward. The engine had suffered extensive damage to the crankshaft, connecting rods, main bearings (which had been carrying the thrust), crossheads and the axial vibration damper. The bedplate had also suffered damage.

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. The following factors are considered to have contributed to Osco Star sustaining considerable damage during tropical cyclone Justin:

1. Timely action was not taken to avoid an encounter with the tropical cyclone.

2. A proper appraisal of the possible movement of the cyclone was not made, and no account taken of the steady fall in barometric pressure and lack of wind directional shift, which resulted in Osco Star passing close to the centre of the cyclone.

3. There was no full exchange of views, in line with Bridge Resource Management procedures, on the developing situation and the appropriate action to be taken. 4. Reliance was placed upon the wind conditions being experienced beyond the immediate area of effect of the cyclone, rather than on the Bureau of Meteorology's predicted wind strengths.

5. The poop and boat decks were not properly secured against the ingress of water into the steering flat and the emergency generator room, which occurred during the cyclone and which initiated the events which led to electrical, and subsequent mechanical, damage.

6. The design of the bulwark around the poop deck prevented the rapid freeing of water trapped in that area and probably contributed to its ingress into the emergency generator room.

7. The design of the weathertight, rather than watertight, doors and flaps and the poor design of the access to the emergency generator room for electrical shore connections, contributed to water gaining access to those spaces which open onto the poop deck.

8. The design of the ship's 24-volt system and associated alarms was such that the battery voltage was able to drop to a critical point where the engine safety system was disabled, without the ship's engineers becoming aware of the situation.

9. The ship's staff appeared unaware of the fact that;
- Removal of the fuses in the 24-volt rectifier/charger unit would stop all running pumps including that for main engine lubrication.
- The main engine would not stop while the fuses were out.
- After failure of the 24-volt rectifier/charger unit, the system was running on the back-up batteries and they seemed unaware of the consequences of the discharge of these batteries.

10. The loss of voltage from the back-up batteries, as they discharged, caused contactors in the Pumps Automation System to drop out and the running lubricating oil pump for the main engine to stop.

Summary

On the morning of 13 April 1997, the tug Wambiri was assisting in the departure of the Singaporean flag vehicle carrier Salome from berth No. 2 North Quay, in the port of Fremantle. Wambiri was made fast aft and was using its own, forward towline, the eye of which was placed over a bollard on Salome's poop. After Salome had been manoeuvred clear of the berth, Wambiri was instructed to accompany the vessel on a slack line until the Pilot was satisfied he had steerage way.

When the order was given to let go the tug, before Salome's crew could lift the eye off the bollard, weight quickly came on the towrope, the Tugmaster misinterpreting the signal to slack away as heave away. The towrope parted in the eye and, recoiling, struck one of the tug's integrated ratings, who suffered severe internal and external injuries.

Conclusions

These conclusions identify the factors contributing to the incident and should not be taken as apportioning either blame or liability.

The towrope, which injured the rating aboard the tug Wambiri, parted at the bollard aboard Salome, after the Tugmaster quickly took the way off the tug before it had been let go.

The following factors are considered to have contributed to the incident:

• Low level of alertness, and possible acute fatigue, of the Tugmaster, caused by the recent shift change.
• The misinterpretation of the signals made by the crew on the poop of Salome.
• The uni-lever in the neutral position, to slow the tug down, expecting the towrope to pull clear, before the eye was seen to be clear of the Panama lead on the vessel. This resulted in the rapid stopping of Wambiri before the towrope had been removed from the bollard on Salome and a consequent shock loading of the towrope.
• It is possible unidentified damage to the eye of the towrope, sustained on some earlier occasion, which resulted in the towrope being less resilient to shock loading.

Also of relevance is the lack of Bridge Resource Management procedures and communication aboard Salome, in that the 2nd Mate was unaware of the Pilot's intended retention of the tug and misinterpreted the slack line to mean the tug wanted to let go.

Summary

On the afternoon of 13 March 1997, the Royal Australian Naval patrol vessel Fremantle left an anchorage off the Flinders Group of Islands, at the eastern side of Princess Charlotte Bay, and, in company with two other patrol boats following astern, commenced passage for Thursday Island. The vessels followed a planned route utilising the inner route of the Great Barrier Reef at a speed of about 15 knots.

At this time the Australian bulk carrier River Embley was on a south bound loaded passage approaching Piper Reef some 150 miles to the north. River Embley was loaded to a draught of about 12.2 m and while underway, at speeds of between 13 and 14 knots, was drawing about 13.5 m allowing for squat. The navigation was under the direction of a licensed Reef pilot.

At about 2100, the three warships were approaching Heath Reef from the South and River Embley was approaching the reef from the north. The depth of water in the area meant that River Embley was obliged to keep to the eastern side of the two-way route and pass about 3 cables off Heath Reef. VHF contact between those on the bridge of HMAS Fremantle and River Embley was established and the message passed that River Embley was a deep draught vessel and the distance the Pilot intended passing off the Reef. The vessels were closing at about 28.5 knots on nearly reciprocal courses with the first two of the three patrol boats crossing ahead of River Embley.

A few minutes after 2100, the lead patrol boat HMAS Fremantle crossed ahead of River Embley, followed by the second vessel in line, the third altered course to pass between River Embley and Heath Reef. HMAS Fremantle made a number of slight alterations and, at about 2108 the rudder was put 20 to starboard. The patrol boat collided with River Embley. There were some slight injuries sustained aboard the patrol vessel as a result of the collision, but nobody on either vessel was seriously hurt. No pollution resulted from the collision.

Damage was sustained to the port side of the patrol boat and some damage was caused to the hull plating close to River Embley's bow and further aft in way of number 3 ballast tank.

Conclusions

These conclusions identify the different factors which contributed to the circumstances and causes of the incident and should not be read as apportioning blame or liability to any particular organisation or individual.

The collision between HMAS Fremantle and the bulk carrier River Embley was caused by the alteration to starboard of HMAS Fremantle when on River Embley's starboard side. The alteration by HMAS Fremantle was made at such a time that, regardless of being constrained by her draught, River Embley could not have taken any action that could have avoided the collision.

The reasons for HMAS Fremantle's actions are the subject of a Naval Board of Inquiry. They involve a complex chain of human factors, which include, but are not limited to:

• incomplete passage and contingency planning
• being unaware of the traffic in the reef
• lack of experience in traffic encounters within the Great Barrier Reef
• the decision to apply 20 of starboard helm based on incomplete and scanty information.

The absence of the deep draft signals on River Embley cannot be said to have directly contributed to the casualty. The patrol boats were advised that she was constrained by her draught, and this was apparently acknowledged. However, had the signals been exhibited, they may have provided an additional prompt for those on Fremantle, as may the use of the Aldis lamp to attract attention had it been easily to hand.

Summary

Early on 13 March 1997, the Cypriot flag bulk carrier Aikaterini L was lying at anchor off the Western Australian port of Geraldton, where it was to load a cargo of mineral sand and barley. In ballast, the 20,297 tonnes deadweight vessel had a calculated draught of 4.1 m forward and 5.67 m aft. The anchor was weighed at 0640 and at 0700 the Duty Harbour Master boarded to pilot the vessel to its berth.

After an exchange of greetings and brief formalities, and with the telegraph on full manoeuvring speed, the Harbour Master steadied the vessel on a south-easterly course, to pass about 300 m seaward of the Pimple Buoy, an orange marker buoy protecting the wave-rider buoy to the north of the entrance channel. His intention was to alter course to port tightly around the Pimple Buoy, into the entrance channel.

'. However, when the ship had turned through about 45, a shudder went through the vessel, followed by a second shudder a few seconds later.

The vessel continued to make way and tests showed that both the steering gear and the main engine were fully functional, so the vessel was berthed as planned. However, underwater inspections by divers on 14 March revealed substantial damage, with hull penetration into double bottom ballast tanks beneath holds 2 and 4. There had also been an ingress of water into No. 4 fuel oil tank, but no pollution occurred.

After temporary underwater repairs had been carried out, Aikaterini L sailed from Geraldton in ballast on 19 March, bound for Singapore to undergo permanent repairs.

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. Aikaterini L came in contact with a charted rock ridge to the south of the entrance channel after the Harbour Master overshot the intended alter-course position to the west of the Pimple Buoy. The following factors are considered to have contributed to the incident:

1. A loss of concentration and awareness by the Harbour Master.
2. A reduced alertness on the part of the Harbour Master, due to the combined effects of his work regime and a slight sleep dept.
3. The Harbour Master's instinctive order of 'hard a port' when he realised, he had overshot the wheel-over position.
4. The pressures induced by the local environmental conditions and the local commercial climate.
5. The absence of Bridge Management procedures, as a result of which: i. the pilotage plan was not discussed; ii. the Master and Third Mate were not fully informed of the Harbour Master's intentions and so were unable to monitor his actions; iii. the Master and his officers had not drawn up their own pilotage plan and the vessel's progress was not monitored properly, so the overshoot was not recognised.