Summary

Shortly after 0900 on Saturday, 2 December 1995, the Singapore registered bulk carrier Sea Crane, while bound for the port of Wallaroo to load a part cargo of barley, grounded off Tiparra Reef in the Spencer Gulf, South Australia. The water ballast in the upper wing tanks was dumped and the vessel refloated after about 1 hours under its own power. Inspection by divers on 3 December revealed that only minor damage had been sustained, the hull plating not having been penetrated.

Originally the vessel had orders to load at Portland and Geelong, in Victoria, and the Master obtained the necessary navigation charts at the previous voyage discharge port of Yokkaichi, Japan. However, after sailing from Japan the Master received a change of orders, initially directing him to load at Ardrossan and Port Giles in South Australia, but this was then changed to Wallaroo and Port Giles. Although the Master requested that the necessary navigation charts be supplied at the Gladstone anchorage, Queensland, where the vessel was to take on bunkers, he did not receive them.

To assist him in navigating from Cape Nelson, Victoria, to Wallaroo, the Master constructed a chart on a celestial navigation plotting chart, taking details from the small-scale chart Aus 4709, "Southern Ocean -Australia South Coast". However, this chart did not show details of lights and shoals within Spencer Gulf.

Conclusions

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

The main contributing factors to the grounding of Sea Crane on Tiparra Reef are considered to be:

1. The Master was not provided with the necessary navigation charts for the safe conduct of the voyage beyond Cape Martin, eastern South Australia and for the approach to Wallaroo in particular.
2. The lack of co-ordination between the owner and the charterer, resulting in charts not being provided at Gladstone on 26 November 1995.
3. The apparent lack of appreciation by the owner of the importance for the charts to be supplied to the ship before it arrived in South Australian waters and, therefore, the fact that the owner did not arrange for the ship to divert to another port en route for this purpose.
4. The Master accepted the non-delivery of the charts and did not request the owner to arrange their delivery at another port en route.
5. In compiling his own chart, the Master did not utilise all the relevant information available to him in the Admiralty publications.
6. Having observed a structure and a number of fishing craft in proximity to it, the Master did not maintain a sufficiently safe passing distance.
7. The echo sounder was not used to check the depth of water and the trend of the seabed, particularly while approaching the structure.

Summary

The 135,000-tonne deadweight bulk carrier Goonzaran anchored four miles off the Port of Newcastle, New South Wales, at 2200 on 20 November 1995, to load a cargo of coal. The vessel was scheduled to berth on 25 November.

The 38,305 tonne deadweight bulk carrier New Noble anchored about four miles off Newcastle, at 0955 on 22 November, about 1.2 miles south of the Goonzaran. New Noble was also to load coal and was due to berth about midday on 24 November.

At 0000 on 23 November, the wind speed and direction recorded at Nobbys Head signal station was from the south-east at eight knots (force 2). At 0700, the wind speed had increased to 16 knots, veering to the south-south-east and increasing to 30 knots by 0800. At 1000, the wind speed had risen to 38 knots from the south-south-west.

With the increasing wind speed and heightening sea and swell, the New Noble's Master ordered the engine should be ready for immediate use, but the ship reportedly maintained its position throughout the morning. At about 1400 on 23 November, the Master became concerned that the vessel was dragging anchor to the north. The bulk carrier, Goonzaran, was the closest ship, lying to the north and in the line of drift of New Noble.

At about 1420, the Mate was sent forward with three crew members to weigh anchor. At about this time the Masters of Goonzaran and New Noble made contact on channel 6 VHF and the Master of New Noble informed Goonzaran that he was weighing anchor. New Noble's engine was used to try and take the weight off the anchor cable and five and a half shackles (150 m) was recovered, but the windlass could not recover the final three shackles.

At approximately 1448, New Noble had closed to about 3 cables (550 m) from the bow of Goonzaran and New Noble continued to drag anchor towards the larger ship. On board Goonzaran the engine had been put on stand-by and the Mate and three crew were forward by the windlass. At about 1450, Goonzaran paid out a further 90 m of anchor cable, to 12 shackles. However at about 1458, New Noble's anchor fouled Goonzaran's anchor cable drawing the ships together, before clearing itself a few minutes later.

At 1500 New Noble collided with Goonzaran in way of number three hold and then passed down Goonzaran's side making two further contacts.

Once clear of Goonzaran, New Noble recovered its anchor and after checking for ingress of water put out to sea to await port entry.

Goonzaran suffered significant damage to the hull and deck plating. New Noble suffered relatively minor damage to the bow at the forecastle head level and an indentation in its bulbous bow. Nobody was hurt as a result of the collision.

On 24 November, both ships were brought into port for inspection and necessary repair.

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 collision between New Noble and Goonzaran:

1. The Master and watchkeeping deck officers aboard New Noble did not appreciate that the ship had dragged anchor from its original position, indicating that the combination of the depth of water, holding ground and ship's freeboard combined to make the anchorage insecure and alert them to the increased risk of dragging anchor in deteriorating weather.
2. The Master and watchkeeping deck officers aboard New Noble did not detect the early signs of dragging and increased the risk of an accident by not reacting sufficiently early to the dragging of the ship's anchor.
3. The need to monitor the ship's position from a consistent set of reference marks was not fully appreciated by the Master and officers on board New Noble.
4. The limitations of the anchors was not fully appreciated by New Noble's Master.
5. Inadequate communications between the two ships meant that Goonzaran's Master was unaware that New Noble's anchor could not be recovered before the collision occurred.
6. New Noble's Master was preoccupied with the recovery of the anchor and did not drive the ship ahead, either dragging the anchor or releasing the bitter end and allowing it to pay out, while the opportunity existed.
7. New Noble's Master undertook no contingency planning regarding recovery of the anchor, nor did he think through his intended action or make any realistic assessment of how long it would take to recover the anchor.
8. New Noble's position relative to the most imminent danger, Goonzaran, was not monitored while trying to weigh anchor.

The Inspector also concludes that:

1. The decision by New Noble's Master not to drop the port anchor was sensible in the circumstances.
2. Goonzaran's Master had the option of slipping his ship's anchor cable and this may have avoided the collision.

Summary

The 46,265 deadweight tonne livestock carrier Mawashi Al Gasseem arrived in the port of Adelaide on 7 September 1995 to load fodder and water. The vessel was on a ballast voyage from Jeddah, in Saudi Arabia, to Napier, New Zealand, where it was to load a cargo of sheep for the Middle East.

Mawashi Al Gasseem was built as a tanker in 1973 and converted to a livestock carrier in 1983. At sea, steam for fuel heating, deck machinery and hotel services is provided by an exhaust gas economiser unit, while in port it was provided by a single Hitachi Zosen two-drum, water-tube, oil-fired auxiliary boiler.

On the morning of 9 September 1995, Mawashi Al Gasseem was at No.1 berth, Outer Harbour, Adelaide, with the auxiliary boiler in use supplying steam for the auxiliary services. The oiler on watch had joined the ship, for the first time, the previous evening. Shortly after coming on watch, he began to encounter problems maintaining steam pressure and water level in the boiler. At about 0920, when he was asked to supply steam to the deck machinery, he called for the assistance of the Fourth Engineer, who, when he saw the low water level in the boiler, immediately shut off the fuel to the burner.

Five or ten minutes later, the Fourth Engineer saw what he believed was still a fire in the furnace, but was, most probably, the boiler internals glowing white hot. He shut off all the valves in the fuel system, but the fire appeared to continue burning and the boiler casing around the aft end of the side water-wall began to glow red hot and give off smoke.

The ship's staff used a number of foam and CO2 extinguishers in an attempt to cool the casing. Hoses were then rigged and used to cool the casing more effectively. At 0950, the fire brigade was called and arrived at 0957, by which time the apparent fire in the furnace seemed to burn itself out and the furnace was cooling down. The fire brigade took over from the ship's staff and continued for the next hour to cool down the boiler casing.

After some inspection doors in the casing had been removed, a cursory inspection of the boiler gave the impression that, apart from some distorted tubes, it had suffered no damage. However, when the Chief Engineer went into the furnace that evening, he found that the boiler had been severely and extensively damaged. The side water-wall and refractory had collapsed, the rear water-wall was burned out and most of the screen tubes were burned out. Most of the furnace tubes in way of the radiant heat from the burner showed signs of having reached white heat and had begun to melt.

The evidence indicates that the damage to the boiler was caused primarily by the burner being fired without water in the tubes. Accumulations of soot, oil and scale on the boiler tube surfaces, caused by poor operating and maintenance procedures, may have contributed to the apparent fire.

The incident was investigated by the Marine Incident Investigation Unit under the provisions of the Navigation (Marine Casualty) Regulations.

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.

It is concluded that:

1. The extensive damage to the boiler water-walls, refractory and screen tubes in the auxiliary boiler of Mawashi Al Gasseem was caused by firing the oil burner after the water level had been lost, following a failure of one or more boiler tubes. Indications of a tube failure were present 1 hours or more before the apparent fire.
2. The subsequent symptoms of fire were caused by overheating of the port side boiler casings by intense radiant heat from the furnace, after a collapse of the refractory behind the water-wall on the port side of the furnace.
3. A build-up of soot and oil on the tubes and water-walls may have contributed to the incident, these deposits occurring due to poor operating and maintenance procedures.
4. The boiler water level, observed by the watchkeeper, in the gauge glasses may have borne no relation to the actual level in the boiler on account of the steam cocks on the gauge glasses having been shut and no gauge glass drill was carried out to check the accuracy of the level shown in the glasses.
5. The main factor leading to the failure of the first tube, causing loss of water level, was progressive tube wastage, due in turn to the age of the boiler, lack of maintenance, poor combustion control and insufficient control of the chemical parameters of the boiler water.
6. The investigation revealed, among those of the crew who were interviewed, a considerable lack of knowledge and experience in the operation and maintenance of steam plant.
7. Had the automatic control systems on the boiler been in good working order, the incident would probably have been prevented, as the fuel trip valve would have shut off fuel to the burner as soon as the water level dropped.
8. The ship's crew successfully contained the heat from the furnace until the fire brigade arrived by which time the furnace had begun to cool down, however, there was an unnecessary delay before hoses were used to cool the boiler casing.
9. The initial reaction to the fire by the Master and crew was not in accordance with the prescribed and practised procedures in as much as the Master did not take control of the situation from the bridge and there seems to have been some confusion and a degree of panic in the response by the crew.
10. There was a delay in calling the fire brigade, exacerbated by the absence of a telephone on board the vessel and the Inspector considers that a more immediate and reliable means of contacting the emergency services should have been used. VHF radio was not used to contact the port authorities to advise them of the situation and they were eventually informed of the incident via a fourth-hand report.

Summary

The 16 m landing barge Keppel Trader sailed from Darwin, Northern Territory in the early hours of the morning on 6 August 1995, bound for the port of Wyndham in Western Australia. On board were the Master and one deckhand.

On its deck, the barge was carrying a cargo of materials and equipment to enable it to be put on to a low-loader at Wyndham and transported overland to Lake Argyle. There it was contracted for thirteen weeks, to move equipment and stores during work on the Ord River hydro electric scheme.

The voyage plan was for the vessel to hug the coast, from Darwin to a position near Port Keats where, if necessary, it would anchor and wait for suitable weather conditions before making the crossing of the south-eastern corner of the Joseph Bonaparte Gulf at the mouth of the Victoria River. Strong south-easterly winds were forecast.

At about 0400 on 7 August, the vessel was south of Cape Hay when the Master handed the watch over to the deckhand instructing him to follow a course approximately one mile off the coast. The Master then turned in for a few hours sleep.

At some time before 0700, the Master was awakened by the motion of the vessel and found that it was in rough seas and approximately six miles off the coast, west of Pearce Point. The wind was blowing from the south-east at 25-30 knots and an estimated 3.5 m sea was running. He decided to run with the weather for a while, but after a further twenty minutes turned on to a reciprocal course and headed back into the weather towards the lee of the coastline.

The vessel made no headway into the weather. After a while, the deckhand went down the engine room hatch, situated on the main deck, to carry out engine checks. He had been gone for about five minutes when the barge suddenly developed a loll. The Master left the wheelhouse and when he reached the deck, the barge appeared to be sinking by the stern. A few seconds later it rolled to port and capsized, settling in a stable, upside down, attitude. Both men were thrown into the water.

The Master twice managed to swim to the exhausted deckhand, who drifted away from the vessel, and twice dragged him back to the upturned barge. After several unsuccessful attempts to get the apparently lifeless deckhand up the sloping bow door, the Master, exhausted, let go of him and the deckhand drifted away.

By that afternoon, the owner of the barge, having not been able to make either radio or satellite phone contact with the vessel, flew his own aircraft down the vessel's intended route but did not find the barge. On the morning of 8 August, when Keppel Trader still had not arrived at Wyndham and there had been no communication with the vessel, the owner advised the Marine Branch of the Northern Territory Department of Transport and Works, which contacted the Maritime Rescue Coordination Centre, and a search and rescue (SAR) operation was initiated.

The Master was rescued late that afternoon by an army helicopter, after spending some 34 hours on the upturned hull and in the water.

Two weeks later Keppel Trader was towed back to Darwin having been salvaged and righted.

Although Keppel Trader is under survey by the Marine Branch of the Northern Territory Department of Transport and Works, it was on an inter-State voyage and thus came under the provisions of the Navigation (Marine Casualty) Regulations.

Conclusions

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

The Inspector concludes that Keppel Trader capsized due to the ingress of seas shipped into the engine room after the hatch in the weather deck was left open while the deckhand was carrying out engine checks. The following factors are considered to have contributed directly to the incident.

1. Keppel Trader was loaded at Darwin in such a manner that the vessel's stability did not meet the criteria of the USL Code Section 8, Sub section C.16 (for landing barges). The effect of the free-surface formed in the engine room bilge was exacerbated by this reduced stability which existed before the flooding began.
2. No stability calculations were undertaken before sailing from Darwin and the investigation revealed a lack of understanding of the principles of stability as applied in the Trim and Stability booklet.
3. The weather deck hatch was not marked `To be kept closed at sea' and the practice had arisen of always using this hatch, in spite of the emphasised warning contained in the Trim and Stability booklet.
4. The internal hatch, which should have been used for access to the engine room under the prevailing conditions, had been stacked with cartons of soft drinks when the vessel was stored with provisions, indicative of the fact that this hatch had fallen into disuse, even in heavy weather.
5. It is considered that the long-standing defects in the wheelhouse panel temperature gauges contributed to the incident, in as much as the Master felt compelled to check the engine temperatures on the local gauges at a time when the vessel was in difficulties.
6. Keppel Trader was proceeding on an inter-State voyage and as such came under the provisions of the Navigation Act 1912. No exemption under section 421 from certain provisions of the Act was obtained, or applied for in writing, from the Australian Maritime Safety Authority prior to Keppel Trader sailing from Darwin.
7. In the opinion of the Inspector, the manning of the vessel was inappropriate for a voyage of the duration of that being undertaken and Keppel Trader should have carried two qualified bridge watchkeepers.
8. The Inspector considers that insufficient attention was paid to the weather forecasts issued by the Bureau of Meteorology, both before the start of the voyage and after departure from Darwin, in particular the strong wind warning which was current for three days before the vessel's departure.

In addition, the Inspector considers that:

1. It would have been prudent to have alerted the Northern Territory Police to the loss of contact with the barge after the owner had overflown the vessel's intended route on the afternoon of Monday 7 August, and it had not been sighted.
2. The Master made commendable efforts to save the deckhand following the capsize and the Inspector considers he did everything possible under the circumstances.

Summary

On the morning of 10 July 1995, the Australian operated 37,557 tonnes deadweight bulk carrier Iron Baron arrived and anchored off the entrance to the River Tamar, Northern Tasmania. The ship was bound for the TEMCO terminal at Bell Bay, where it was to discharge 23,896 tonnes of manganese ore. The Master was advised that the Pilot would board at 1930.

When the crew went to stations to weigh anchor at 1900, the wind was from the north-north-west at 20 to 25 knots. The anchor was aweigh at 1913 and, after turning the vessel around, the Master manoeuvred the ship, at minimum manoeuvring pitch on the propeller, towards the pilot boarding position. So as to maintain a lee on the port side for the pilot launch, he adjusted the heading from south-south-west to south-west.

The Pilot boarded at 1933 and as soon as the launch was clear of the ship's side, the Master, aware that he had overshot the boarding position, ordered the wheel hard to port and the telegraph dead slow ahead, to bring the ship around on to the leads.

After an exchange of information with the Master, the Pilot ordered full ahead, to increase the rate of swing, and went to the port bridgewing, to check the lie of the leads. Using binoculars, he saw that the ship was too far to the south and likely to run aground on the eastern end of Hebe Reef. He therefore ordered hard to starboard, hoping to clear the northern edge of the reef. However, after turning through about 40, the ship grounded at a speed of about five knots, in a position 1.8 cables (333 metres) north of Hebe Reef beacon.

Attempts were made to refloat the ship, initially by going full astern and later with the aid of a tug, but these were unsuccessful. With the tide ebbing and the weather deteriorating, the movement of the ship became violent and progressive damage to the bottom plating became evident, with a number of tanks being ruptured.

When fuel oil was seen in the water, the Master mustered the crew and ordered the disembarkation of some of them, eventually ordering the disembarkation of the remainder at about 0645 on 11 July. Iron Baron was eventually refloated by salvors on 16 July. After extensive inspection of the vessel, both internally and externally by divers, and discussions with the Launceston Port Authority, the decision was made that Iron Baron should be scuttled. The vessel was towed to the position 39 37S 149 25E, 60 miles east-northeast of Flinders Island, where it was scuttled in 4000 metres of water on 30 July 1995.

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.

It is considered that by the time the Pilot arrived on the bridge and assumed control of the conduct of the vessel the grounding could not be avoided.

The following factors are considered to have contributed to Iron Baron grounding on Hebe Reef:

1. A full passage plan, detailing safe clearing distances and bearings to be used while picking up the Pilot, had not been prepared, and proper management of the bridge resources had not been considered.
2. Due consideration was not paid to the effects of the strong northerly wind and south flowing flood tide when manoeuvring to pick up the Pilot.
3. The vessel's progress was not monitored by plotting positions on the chart.
4. Although navigating by radar, no safety distances or bearings were drawn on the reflector plotter.
5. The Mate did not monitor the Master's actions, nor did he check the vessel's position by radar.
6. In relying upon the radar for information on the vessel's position, the Master
   a) was initially under the impression that Iron Baron was a mile further from the pilot boarding point than would have been the case.
   b) appears to have made no allowance for the fact that the beacon is located on the south side of the reef, that the shallows extend 2.5 cables north-east of the beacon and that the vessel's bow, 150 metres forward of the bridge, reduced the indicated distance off the reef by almost one cable.
7. The Master and the Deck Officers had not been given specific directions that passage planning was to include pilotage sections.
8. Although the Master was appropriately qualified, he had not been provided with all available training for the safe handling of ships before being appointed to his first command.

Summary

On Saturday 17 June 1995, the Australian bulk carrier Iron Prince collided with the fishing vessel Pisces to the west of Cape Nelson, Victoria at 0644 Australian Eastern Standard Time. The weather at the time was clouded sky with passing showers and gale force winds with a heavy sea and swell.

Iron Prince was on passage from Hay Point, Queensland, to Whyalla, South Australia, with a cargo of coal. The bridge watchkeepers did not see the fishing vessel in sufficient time to take full avoiding action.

Pisces, engaged in gill net shark fishing, was lying at anchor in proximity to the western end of its streamed nets. No lookout was being kept, the crew being asleep and, as the anchor light had failed, the lights being shown provided less chance of the vessel being seen by ships approaching from well abaft the beam.

After the collision, Iron Prince turned about and escorted Pisces, which had sustained damage but was still able to proceed safely, to Portland harbour.

No one was injured in the incident and there was no pollution.

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.

1. The manning on the bridge of Iron Prince was appropriate and the visual lookout alert. However, the lights being shown by Pisces were not seen in sufficient time for full avoiding action to be taken.
2. The lights being shown by Pisces on the night of 16/17 June 1995, were not those prescribed in the regulations for a vessel at anchor and greatly reduced the chances of early detection by a vessel approaching from astern or on the quarter.
3. There was no lookout being kept aboard Pisces.
4. The minimum safe manning requirement for Pisces, as detailed in the Uniform Shipping Laws Code and the State of Victoria marine regulations, makes the maintaining of a lookout at all times impractical.
5. The electrical supply, as required by regulation, aboard Pisces, was inadequate to provide sustained power to the deck lights when the engine was stopped.
6. The timber construction of Pisces made the vessel's detection by radar unlikely in the prevailing heavy sea conditions.
7. The Master of Iron Prince, in making contact with Pisces, in advising the authorities of the collision and in escorting Pisces to Portland, acted appropriately after the incident.

Summary

The Danish owned vessel Svendborg Guardian sailed from Townsville at about 2000 on 23 June 1995, on its regular service between Townsville and the port of Kiunga, on the Fly River, Papua New Guinea.

The ship had been engaged on this service since 1988 and habitually followed a route inside the Great Barrier Reef between Townsville and Cairns, and then by the Grafton Passage, through the Coral Sea to the Fly River.

At about 0400 on 24 June, the ship failed to make a course alteration off Brook Islands and maintained a straight course to run aground south of Murdering Point, Queensland at about 0600.

Immediate attempts to refloat the vessel were unsuccessful as the tide started to fall. The ship was towed off the ground by the tug Otto Tasman at about 1830 on 24 June. The vessel was subsequently towed to Cairns for inspection.

No significant damage was found, and the ship resumed its voyage to Kiunga on the afternoon of 26 June.

Conclusions

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

Svendborg Guardian grounded as a result of a number of factors which combined to contribute to the grounding:

1. There was nobody on the bridge for a period of almost five hours with the ship effectively out of control.
2. The bridge was unmanned because the Second Mate left the bridge at shortly after 0105 and failed to return because he fell asleep.
3. The Second Mate was suffering from extreme fatigue as a result of poor-quality sleep from 18 June to 23 June and his decision not to sleep after the ship left Townsville. This decision, prompted by his desire to watch a rugby league match rather than ensure he was as fit as possible to take his watch, displayed inexperience and irresponsibility.
4. There was no look-out stationed on the bridge, and the ship was not equipped with any other system to alert the Master and crew in the event of the officer of the watch being incapacitated or otherwise not able to perform his/her duties.
5. The absence of a look-out made the accident inevitable once the Second Mate had fallen and remained asleep, because there was nobody to rouse the Second Mate, call the Mate or summon the Master.
6. The Master, Mate and Second Mate were all fatigued to a significant degree.
7. The Master in command on 24 June had ordered that a seaman should act as look-out during the hours of darkness. This instruction was not complied with possibly due to a misunderstanding and a lack of effective communications in the form of written notification, and because of the entrenched practice for the officers to keep a watch alone during the night.
8. The Owner's standard instructions did not give clear direction to the ship's masters to comply with the STCW Convention requirements.
9. The habitual practice of not posting a look-out should have been detected by the ship operators and rectified.

Summary

The 182 m long, Australian flag bulk carrier River Torrens arrived off the Port of Newcastle, New South Wales, at 2100 on 31 May 1995, loaded with about 27,000 tonnes of wheat from South Australian ports. At 2107, a licensed pilot for the port boarded the ship to take the vessel to no. 3 berth, the Western Basin Grain Terminal. The night was fine, partly cloudy, with a light north-easterly wind and a swell of about 1.6 m at the harbour entrance.

The vessel's bridge passed the outer end of the Southern Breakwater at 2123. The vessel was to the south of the transit of the main leading lights and turning to port, although full starboard rudder had been applied. The vessel's speed at the time was estimated to be 8 to 9 knots. As soon as the vessel was in the lee of the Southern Breakwater, the vessel's speed was reduced to half ahead and then, after about a minute, to slow ahead.

River Torrens steadied as it approached no. 2 buoy and, as the vessel then began to swing to starboard, full port rudder was applied to counter the swing and avoid no. 2 buoy. However, the propeller and rudder came into contact with the steeply shelving channel bank 80 m east of no. 2 buoy. Although the rudder was kept hard to port and one of the waiting tugs pushed hard on the starboard bow, the vessel continued across the channel.

The Pilot ordered the anchors to be let go, but before they could be released the vessel grounded on the northern side of the channel at 2127, about 10 minutes before high-water.

After initial attempts to refloat the vessel, both tugs were positioned at the ship's stern to tow the vessel off the bank. Using the ship's engine and tug power, the ship was refloated at 2147 and resumed passage for the grain berth.

An inspection of the ship showed all propeller blades were damaged, the lower half of the spade rudder was bent to an angle of about 30 degrees from the vertical and some damage to the main engine crankshaft was evident. Forward, there were some superficial scrape marks to the bottom paint work. On 4 June, River Torrens entered dry dock where further assessment of the damage was made and repairs to the vessel began.

Conclusions

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

The Inspector is satisfied that neither alcohol nor drugs (prescribed or illicit) were factors in this incident. The Inspector considers that the following factors are relevant to the contact made by River Torrens with the south bank of the channel, about 80 m east of no. 2 buoy:

1. The port entry had been inadequately planned by both the Pilot and ship's staff and insufficient action was taken to ensure River Torrens was in the intended position at the harbour entrance.
2. As the ship approached the harbour entrance the ship was south of the leading transit delineated by the 'deep water' leading lights.
3. When the vessel turned to enter harbour it was south of the transit delineated by the main leading lights.
4. There was an acceleration in the rate of turn of the ship as it passed the Southern Breakwater head and, because the ship was towards the south side of the channel, there was insufficient room for the situation to be recovered.

The absence of any planning of the port entry by the Master of River Torrens meant that the pilotage could not be effectively monitored and the ship's officers were not sufficiently alert to the significance of the ship's position relative to the leading lights, resulting in reduced support to the Pilot.

1. The planning and communication between the Master and Mate, the Master and Pilot, and the bridge team and the forward anchoring party was ineffective.
2. The bridge organisation, with the Master relaying the Pilot's orders and an experienced officer standing by the telegraph, did not allow for a physical check to be made of the ship's position.

The following factors contributed to River Torrens taking the ground on the northern bank:

1. After contact with the southern channel bank, the existing forward momentum, combined with the astern movements of the engine, maintained the ship's turn to starboard.
2. Although it is problematic whether, had the anchors been dropped immediately when ordered, one or both anchors would have prevented the ship taking the ground, the fact that they were not cleared must be considered a factor in the incident.

Summary

The German flag container ship Carola sailed from Sydney on the afternoon of 25 March 1995, bound for Singapore by way of the inner route of the Great Barrier Reef.

At 0100 on 29 March, the vessel embarked a licensed pilot off Cairns for the passage through the inner route to Goods Island. The vessel made good a speed of marginally over 15 knots.

At about 0230 on 30 March, the Pilot left the bridge in an area where there was to be no alteration of course for about two hours and where other shipping and fishing boats presented no potential hazard. The Pilot gave clear directions to the Second Mate, the officer of the watch, that he was to be called at a position that he had marked on the chart, or if the mate had any concerns.

At a little after 0400, the Mate relieved the Second Mate, who passed on the instruction about calling the Pilot.

At 0458 on 30 March, Carola ran aground on South Ledge Reef.

The Master, who was asleep in his cabin, was woken by the change in the characteristic vibration of the ship. He went to the bridge where he found only the Mate and lookout. The Pilot was called from his cabin.

The damage was assessed, soundings of the ship's tanks were taken and the Maritime Rescue Coordination Centre was informed. It was established that the fore peak tank was breached and some water was entering the bow thruster space. However, the ship's pumps were able to handle the ingress of water.

No injury was sustained to the Pilot or any crew member and no pollution resulted from the grounding.

The Carola refloated about six hours later at 1115 on the high tide and, after the Master established that it was safe to do so, the ship continued its passage to Goods Island. It anchored off Goods Island after 1530. In the evening of 30 March, a surveyor from the ship's classification society boarded the vessel and over the next three days the vessel was inspected by divers and repairs carried out, to allow it to continue the voyage to Singapore.

Carola resumed its voyage on 4 April.

Conclusions

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

The grounding was not due to any mechanical failure on board Carola or any deficiency in the navigational aids marking the reef.

The grounding was the result of the Mate neither ensuring the Pilot was called to the bridge at the designated position, nor altering course in the Pilot's absence.

The Mate was overcome by drowsiness which caused him to loose track of time and space.

The Mate's condition was induced by both an intake of alcohol some four hours before going on watch and reduced sleep time. His condition was compounded by the ambience of the bridge and the avaliablity of a comfortable chair at the command position. The conditions on the bridge were not under the control of the Mate, however any intake of alcohol and duration of sleep were under his control.

The rest periods taken by the Pilot, under the prevailing conditions of weather and shipping traffic, were reasonable and in accordance with the practice of Reef Pilots.

The part bottle of beer consumed by the Pilot just before midnight on 29 March would not have impaired his performance or efficiency.

Summary

On 22 February 1995, tropical cyclone 'Bobby' was moving in a west-south-westerly direction off the north-west coast of Australia, gradually increasing in intensity.

At 0600 on 23 February, Bobby was located 136 nautical miles to the north of Dampier and, as a safety precaution, vessels lying at anchor in Dampier Roads were instructed to weigh anchor and proceed to sea.

The Maltese flag, 61,297 deadweight tonnes bulk carrier Bulkazores, one of six vessels at anchor, was the first vessel to clear the anchorage. The Master took the vessel two miles beyond port limits and then hove-to, to ride out the developing storm.

At 0722 on 24 February, the Master of Bulkazores advised Dampier Port Control that Bulkazores was being set towards the shore and, at 1026, the vessel took the ground close to Kendrew Island.

Bulkazores refloated at 1633, at high water, and the Master, on advice from the Harbour Master, let go the starboard anchor. Bulkazores then safely rode out the remainder of the storm. After inspection by divers, the vessel was moved on 28 February, to a position close to Dampier public wharf.

An inspection by divers indicated extensive scratching and paint removal, but only relatively minor indentations in the bottom plating. On 2 March, after an internal inspection confirmed that no tanks had been ruptured, the Classification Society declared Bulkazores fit to load cargo.

Conclusions

These conclusions identify the different factors contributing to the incident, not for the purpose of apportioning blame or liability, but for identifying areas where mariners need to exercise extreme caution and proper planning and bridge resource management in order to prevent a similar occurrence.

The grounding of Bulkazores in shoal water off Kendrew Island, Western Australia, on 24 February 1995, was caused by poor seamanship, in that Bulkazores did not clear the area when the tropical cyclone changed direction and moved towards the Dampier Archipelago, as a result of which the vessel came within the dangerous semicircle of the cyclone and was trapped on a lee shore.

Other decisions and actions, both before Bulkazorres arrived at Dampier and after it was instructed to leave Dampier Roads anchorage, are considered to have contributed to the incident:

The initial recommendation of the weather routing consultant was disregarded, probably in order that Bulkazores would arrive before a competing vessel and, apparently, without taking into account the known behaviour of tropical cyclones off the north-west coast of Australia and their propensity to curve towards the coast.

Despite ample early indication of the probability of strong winds and rough seas being encountered near the coast, additional ballast was not taken in no.4 hold before the weather deteriorated.

The Master relied solely on his own judgement, at no time did he discuss his course of action with his officers, to gain other opinions as to the dangers posed by the cyclone and the appropriate action to be taken.