Summary

Early on the morning of 1 November 1997, the Singaporean flag container ship NOL Amber embarked a licensed coastal pilot to the south-west of Booby Island, for the passage through Torres Strait and the Inner Two-way Route of the Great Barrier Reef. The vessel was at maximum draught, 12.2 m even keel, for the passage.

After boarding, the Pilot explained to the Master that there was a two-hour tidal window for negotiating Varzin Passage and that the vessel would then have to 'lose' about one and a half hours between Varzin Passage and Prince of Wales Channel, before there would be sufficient water in Prince of Wales to maintain the stipulated minimum under-keel clearance.

Proceeding at slow ahead, NOL Amber cleared Varzin Passage at 0640 and continued, at slow speed, towards the start of the delineated two-way route off Goods Island. The Pilot informed the Master that the earliest time for entry was 0900 and that he would therefore be turning the ship around to head west. The Third Mate maintained a plot of the ship's progress and a helmsman was on the wheel.

At about 0725, the Pilot gave a helm order to start the intended turn to starboard. At 0735, the ship was called by the Duty Officer at the REEFCENTRE and informed that his radar indicated NOL Amber was heading for shallow water. The Pilot replied that he was turning the ship around, to waste time and that 'they were doing all right', but at 0738 the vessel grounded on Larpent Bank.

Immediate attempts to refloat the vessel were unsuccessful, as were the attempts on the next two high tides. However, after discharging most of the ballast, the vessel was refloated, with the assistance of two local vessels, on 4 November. There was no pollution, the vessel suffered minimal damage and was permitted to resume its voyage after an inspection by divers.

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 Pilot did not have a properly prepared plan for the necessary delay between Varzin Passage and Prince of Wales Channel, including the turning about manoeuvre.
2. The vessel's Bridge Team had not prepared a proper passage plan, identifying limiting bearings and safety distances.
3. The Pilot did not fully brief the Master and Third Mate on the manoeuvre, to enable them to operate as a fully integrated, supportive team.
4. The Pilot did not ascertain the vessel's position immediately before starting the manoeuvre.
5. The Pilot did not fully evaluate the situation regarding River Embley before deciding which way to turn the vessel.
6. At the start of the turn, the Master did not satisfy himself that the vessel had sufficient room in which to carry out the manoeuvre.
7. At the start of the turn, the Third Mate did not advise the Pilot on the distance off Larpent Bank.
8. Neither the Pilot nor the Master instructed the Third Mate to keep them informed about the distance off Larpent Bank during the turn.
9. The 0735 position was incorrect.

Summary

Late in the evening of 28 September 1997, the Australian fishing vessel Teresa was lying at anchor about 8 miles south-west of Termination Island, south of Esperance. The Skipper and Deckhand, who had both been engaged in drop-line fishing during most of the day, had gone to bed shortly before 2200.

At about 2245, both men were woken by a loud bang and violent movement, and they realised they must have been hit by another vessel. Climbing into the wheelhouse, they were unable to see anything through the windows, so they went out on deck and the Skipper opened the engine room hatch to check for flooding. Both men then looked upwards and saw, close on the port quarter, the accommodation lights of a vessel. The vessel passed close by to port and moved off towards the east without stopping or making radio contact.

Teresa was found to have sustained considerable damage to the bulwark at the bow. As the anchor rope had snagged the timber on the port bow, the rope was buoyed and cut loose, and the Skipper decided to return to Esperance.

The partly laden, 26,066 tonnes deadweight, Cypriot flag bulk carrier Atlantis Two sailed from Esperance Roads anchorage at 1736 on 28 September 1997, bound for Thevenard, South Australia. After clearing the approach channel, the Master kept the vessel to seaward of the outlying banks of the Recherche Archipelago. No other vessels were sighted during the evening and, at 2345 when 13 miles south by east of Termination Island, course was altered from 122 to 090.

Late on 29 September the Master received a telex message from the vessel's operators, informing him that Atlantis Two was suspected of being the vessel that had collided with the fishing vessel Teresa at 2250 in the vicinity of Termination Island. The Master asked the Third Mate if there had been a collision, or if he had seen the fishing vessel and the Third Mate responded in the negative to both questions.

When Atlantis Two berthed at Thevenard on the morning of 1 October 1997, the vessel bore a recent contact mark on the hull, low down on the starboard bow. Under scientific examination, particles of red paint taken from this contact mark matched the hull paint of Teresa and particles of paint deposited on the damaged bow of Teresa matched the boot-topping paint of Atlantis Two.

Conclusions

These conclusions identify, where possible, the factors that contributed to the incident and should not be read as apportioning blame or liability to any particular organisation or individual. The identification of a two-way transfer of paint between Atlantis Two and Teresa confirmed that Atlantis Two was the vessel that collided with Teresa. From the evidence available, it was not possible to determine categorically what lights were exhibited by Teresa, or whether the Third Mate aboard Atlantis Two was keeping a proper look-out. However, the following factors are considered to have contributed to the incident:

• The bridge of Atlantis Two was not properly manned and was operating contrary to normal safe practice, in that no seaman was assigned to look-out duties, the officer being on watch on his own.
• The Master's decision to release the seamen from lookout duties, in order to maximise their time on maintenance work.
• The absence on board Atlantis Two of a Company Operating Manual, detailing Company policies on safety and bridge manning issues.
• No look-out was being maintained aboard Teresa.
• Teresa was anchored in a sealane, albeit an infrequently used one, when there was a relatively much safer anchorage area seven miles to the north-east.
• The regulatory minimum manning requirements for a vessel the size of Teresa, engaged in the fishing industry, virtually preclude the keeping of a look-out while the vessel is anchored for the night.
• There are no instructions or guidelines to fishermen on choice of anchoring positions.

Summary

The Panamanian flag general cargo vessel Pine Trust sailed from Slope Island Terminal, Shark Bay, Western Australia, at 0930 on 13 October 1997, bound for Japan, with a cargo of bulk salt. Navigation of the vessel was under the conduct of a pilot.

After clearing the berth at 0954, the vessel was steadied on its first heading, and sea speed was ordered. When the Pilot was satisfied with the vessel's position and course, he looked at and discussed documents relating to new procedures for ships with the Master. Course was adjusted due East of Cape Heirisson in accordance with the track on the ship's chart.

After passing No. 9 beacon the Third Mate called the Pilot's attention to the fact that the ship had passed No. 9 beacon and No. 8 beacon should have been on the starboard bow. The Pilot checked the position and realised that the ship was heading for shoal water and was standing into danger. Although action was taken to alter course away from shoal water, Pine Trust ran aground at full sea speed at about 1113, off No. 8 beacon in Denham Channel.

Initial attempts to refloat the vessel using the engine were unsuccessful. A Salvage Master was appointed, and, on 16 October 1997, further attempts were made to refloat the vessel with tug assistance. The vessel was refloated at 2345 that day but lost her port anchor and ten shackles of cable as she came off the sandbank.

After refloating, the tug was cast off and the vessel anchored again for a diver's inspection, in the presence of a Surveyor from the Australian Maritime Safety Authority and a Class Surveyor. Nobody was injured as a result of the incident and there was no damage to the hull, nor was there any pollution. Once it was established that the vessel was seaworthy, the voyage to the discharge port was resumed.

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. Pine Trust grounded off Beacon No. 8, as a result of the course not being altered off Beacon No. 9 to pass safely through the line of beacons marking the narrow-dredged passage at the head of Denham Channel. The following factors are considered to have contributed to the grounding:

1. Lack of bridge team management processes in that:

(a) The Pilot did not communicate details of a passage plan to the ship's bridge team.

(b) There was insufficient communication between the ship's staff and Pilot in regard to progress of the vessel as various beacons were passed.

(c) The Third Mate did not draw the attention of the Master and the Pilot to a deviation from courses laid down. Lack of adequate bridge management was compounded by:

2. Inadequate monitoring by the Pilot of the position of the vessel, prior to passage of beacon No. 10, till the vessel grounded.

3. Loss of awareness by the Pilot of the vessel's position.

4. Inadequate monitoring of the vessel's position by the Master.

5. Loss of awareness by the Master of the vessel's position.

6. Chart corrections were not updated to indicate topmarks on certain beacons.

Summary

The Singapore registered container vessel NOL Crystal sailed from Fisherman Islands container terminal at 0436 on 26 September 1997, at a maximum draught of 11.9 m, bound for Port Botany. The navigation was under the direction of a licensed pilot.

At the time of sailing, visibility was reduced to a little under one mile. As the vessel proceeded along Bar Reach, the visibility improved and speed was increased to full ahead.

The vessel navigated by way of East Channel, Main Channel and Spitfire Channel to North West Channel. VHF radio contact was made between NOL Crystal and a southbound car carrier and it was agreed the southbound ship, at a relatively shallow draft, would stay outside and to the west of the channel. After leaving Spitfire Channel, course was set to leave the next beacon (NW10) to starboard and an inbound ship was seen on the radar.

At 0704, NOL Crystal passed NW10 beacon and, within a minute, entered a fog bank. The ship's speed was reduced and the ship's whistle sounded. A little later the whistle of the inbound ship could be heard as it passed clear to port. The fog was very thick.

At about 0715 as NOL Crystal passed NW3 beacon the Pilot altered the ship's course for the next leg of the channel. About four minutes later the Officer of the Watch told the Pilot that the ship was outside and to the east of the channel.

The Pilot could see that the vessel was slightly east of the transit of beacons NW8 and NW6. The Pilot ordered the engine revolutions to slow ahead followed by a bold alteration to port to bring the ship back into the channel. The Officer of the Watch then reported that the vessel was in the channel and the Pilot ordered an alteration of course to starboard. The ship was slow to respond and two minutes later the Officer of the Watch reported that the vessel was now outside the channel to the west and the Pilot ordered an increase in the helm angle.

The ship reached a heading of 300 and had started to turn to starboard when it grounded at about 0728 on a heading of 315, in position 26 56.3 degrees South 153 11.9 degrees East, with NW8 beacon bearing 021 x 0.57 miles. NOL Crystal refloated without assistance under its own power that afternoon at 1415. After ensuring that the vessel's watertight integrity was intact, the vessel was permitted to continue its voyage. Nobody was injured 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 blame or liability to any particular organisation or individual. The following factors are considered to have contributed to the grounding:

1. The fog conditions resulted in the loss of all normal visual marks and prompts.
2. The Pilot became disorientated in the fog.
3. The Pilot had no blind pilotage system to provide a seamless change in navigation procedures.
4. The alteration of course to clear the inbound ship at about 0710 resulted in the ship being out of position for the alteration of course off NW3 beacon.
5. In the absence of a full voyage plan and blind pilotage system, the Pilot overcorrected the ship's head to regain the channel after NW3 beacon.
6. The Pilot misjudged the return to the channel course and delayed the return to 328 until it was inevitable that the ship would enter the shallow water to the west of the channel.
7. The reduced under-keel clearance affected the handling characteristics of the ship, increasing the turning circle.
8. Once in conditions of restricted visibility, the lack of detailed outward passage plan by the ship's staff resulted in the potential for a 'single person failure' to result in a grounding.
9. Although the ship's positions were fixed at frequent intervals, the positions provided a historical record of where the ship had been. In confined waters historical information is limited in its use to prevent a grounding. It is further considered that:
10. Any discrepancy between the true position and that given by the GPS receiver was not of such a magnitude as to have affected the pilotage of the ship.

Summary

At 2200 on 23 August 1997, the self-discharging bulk cement carrier Goliath was alongside in the port of Devonport, Tasmania, loading a cargo of bulk cement for discharge in Melbourne and Sydney. At about 2202, the ship's fire alarms sounded throughout the accommodation.

Cargo operations were suspended and the Chief and 1st Engineer made their way to the central control station. The ship's fire detection system indicated the alarm had been activated from the transformer room, adjacent to the main switchboard room. Joined by the 3rd Mate they went to the engine room where they could smell burning electrical insulation. The Chief and 1st Engineers entered the switchboard room then the transformer room to investigate, while the 3rd Mate waited in the engine room.

Although the transformer room was filled with quite dense smoke, the two engineers entered, but then noticed that the smoke was coming from the main switchboard room behind them. The smoke was accumulating rapidly, and the men were forced to leave the transformer room almost immediately, before they could locate the source of the smoke.

In the engine room the 3rd Mate relayed the Chief Engineer's assessment to the Master, confirming a large fire and requesting the assistance of the Tasmanian Fire Service.

The 1st Engineer, wearing breathing apparatus, went back into the switchboard room and found the seat of the fire in the main switchboard, in the cubicle containing No.2 generator air circuit breaker.

A team from the Tasmanian Fire Service arrived at 2216 and by 2235 the firemen had extinguished the fire using CO2 and dry powder extinguishers.

Wearing BA, the Chief and 1st Engineers removed the circuit breaker from its cubicle and cooled it with a water hose. The circuit breaker was damaged beyond repair and heat had caused considerable damage to the adjacent cubicles either side of No.2 circuit breaker.

Repairs, which were carried out by contractors over the next 18 days, included the replacement of all the ship's Hyundai manufactured air circuit breakers with new ones manufactured by Terasaki in Japan.

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.

1. The fire in the main switchboard was caused by an internal fault in the air circuit breaker for No.2 generator.
2. Damage to the circuit breaker was such that, on subsequent examination, it was not possible to determine exactly what had caused the fault, although overheating of the centre pole in the main current carrying path was probably the triggering factor.
3. No inspections, in accordance with the manufacturer's recommendations, had been carried out on the ship's circuit breakers since the vessel was delivered, and their first survey was not due until five months after the incident.
4. A heat detector, located above, and very close to, the cubicle containing the No.2 generator circuit breaker proved ineffective at giving an early alarm as heat was contained largely within the cubicle and the main problem was the generation of large quantities of smoke from cable insulation.
5. In general, the response to the fire by the ship's officers and crew was appropriate and, with the assistance of the Tasmanian Fire Service, the fire was successfully confined to No. 2 switchboard cubicle. However, shortcomings in briefings, the use and monitoring of BA sets and dress worn by ship's staff during firefighting are areas that require examination.

Summary

The Australian bulk carrier River Yarra sailed from Cairncross dry dock, Brisbane at 0736 on 31 August 1997, with two tugs assisting. A licensed pilot was in charge of the navigation through the pilotage district. The vessel manoeuvred to mid-stream where the engine was tested for about eight minutes, initially astern and then ahead.

Although there were some fluctuations in engine revolutions, this was identified as a minor problem with the governor, which could be adjusted when clear of the Brisbane River. Following the engine trials the tugs were dismissed.

Through Brisbane Harbour Control, it was known that the tanker Girraween was inbound for the Ampol crude oil berth at Fisherman Islands and that the two vessels would pass in the approach channel. In view of the fluctuations in River Yarra's engine revolutions, the Pilot asked the Pilot on Girraween to delay entry into the Bar Channel until about 0900 when River Yarra was expected to clear the entrance beacons.

As River Yarra passed Fisherman Islands the tug W J Trotter was seen alongside the container berth. At about this time River Yarra's engine revolutions dropped for no apparent reason and, as a precautionary measure, the Pilot called the tug on VHF radio, asking it to escort River Yarra through the Bar Channel.

A few moments later River Yarra lost all engine power. The ship was making about 10 knots and was able to maintain steerage way for 2 miles. The crew of W J Trotter cast off to follow River Yarra along the Bar Channel and the Tugmaster, advised of the engine failure, was requested to take a tow from River Yarra's forecastle so the bulk carrier could clear the Bar Channel.

The tug arrived at River Yarra and passed a line from its bow to the bow of the bulk carrier. W J Trotter is a stern drive omni-directional tug with the ability to tow with nearly equal power and manoeuvrability in any direction, at least at low speeds.

The tug took the weight on the towline and started to tow River Yarra along the Bar Channel. Shortly after the tug made fast, River Yarra's engine was restarted, however the tug was retained in case of further problems. The two vessels picked up speed and cleared the entrance beacons twenty minutes later. River Yarra then started to alter course to starboard and after an alteration of about 10, the two vessels collided causing damage to W J Trotter's hull on the port side, just aft of its mid-length.

Radio contact between the two vessels established that, although damaged, W J Trotter did not require assistance and would make its way back to its berth. River Yarra continued on its voyage.

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 collision:

1. The initial requirement for a tow at short notice, which arose from a lack of appropriate engine room procedures on board River Yarra.
2. A feeling by all involved that, once the ship was under tow, the critical operation to prevent River Yarra taking the ground had been completed successfully, before the tug let go.
3. A lack of precise communications as the vessel cleared the channel between those on the bridge of River Yarra and the Tugmaster of W J Trotter.
4. The speed of the tow, particularly in the bow-to-bow configuration at the time of letting go.
5. The short length of the towline increased the risk of being overrun with any slackening in speed by the tug.
6. The lack of appreciation by the Pilot and Master of the difficulty in controlling the directional stability of W J Trotter when towing stern first at speed.
7. The absence from Pilot training of a full knowledge of tug manoeuvring capabilities.
8. The lack of a mutually agreed procedure for letting go the tug.
9. Inexperience by both the Pilot and Master of releasing a tow at relatively high speed.
10. The absence from the tug's standard operating procedures of information on the limitations of the tug's performance when towing astern.

Summary

On 7 August 1997, the Taiwanese flag bulk carrier Ming Mercy was lying at the anchorage off the port of Port Kembla, New South Wales. It had completed a voyage in ballast from Taichung, Taiwan, and was preparing to load a cargo of 58,200 tonnes of Australian coal for the return voyage to Taichung.

At about 1030 that morning, a fire was discovered on the lower bridge deck by the crew. The fire rapidly gained a hold and filled the accommodation and the bridge with thick, black smoke. In an early attempt to tackle the fire, the Messboy was burned and suffered a broken ankle.

An inbound passing vessel noticed smoke rising from the accommodation of Ming Mercy and notified the Port Kembla Signal Station. The pilot launch was sent to Ming Mercy to investigate and, on arrival, learned of the fire. The shore authorities were notified by the pilot launch and, at 1125, the tug Korimul left Port Kembla with the first team of 13 firefighters from the NSW Fire Brigades. After some difficulty boarding Ming Mercy with all their equipment, via the pilot ladder, they commenced firefighting operations at 1232, entering the accommodation in an attempt to locate the seat of the fire.

A helicopter was despatched to Ming Mercy and, after landing on the hatch covers, flew the injured Messboy to Wollongong hospital. Hampered by intense heat from the bulkheads and steel decks, the fire brigade was unable to prevent the fire from spreading upwards to the upper bridge deck. Due to the heat, firefighters had to work in relays of 20 minutes. The weather deteriorated and, to enable relief crews of firefighters to be exchanged on Ming Mercy, another helicopter was employed running a shuttle service. With the aid of a thermal imaging camera, the fire was eventually brought under control at 1928 and, at 2045, the fire was reported as out.

The forward end of the lower and upper bridge decks was severely damaged by the fire. The bridge suffered extensive smoke damage and buckling of the steel deck. All navigation, control and communications equipment was rendered unserviceable through damage to electrical cables in the decks beneath.

Notable features of the incident were a lack of communication between the ship's officers and the Fire Brigades, due to language difficulties, the absence of any fire detection system aboard the vessel, very sub-standard additional electrical wiring installed in accommodation spaces and the fire-retardant effectiveness of timber and plywood used for the construction of bulkheads within the accommodation.

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 fire started in the forward part of the 1st Engineer's dayroom on the lower bridge deck, then spread upwards to the upper bridge deck.
2. It was not possible to positively identify the source of ignition as the intensity of the fire was such that little physical evidence remained.
3. The remains of 'amateur' wiring extensions, however, found in the 1st Engineer's dayroom, and examples of such wiring observed in many other accommodation spaces, indicate a distinct possibility that the source of the fire was electrical.
4. There was no policy in place aboard the vessel for vetting additional wiring and extensions installed in crew accommodation spaces.
5. The lack of a fire detection system enabled the fire to gain a strong hold before it was detected by the crew.
6. The use of combustible materials in the accommodation, together with the apparently limited effectiveness of the fire-retardant timber used in bulkheads, facilitated the rapid spread of the fire.
7. A limited understanding of English led to language difficulties between the Taiwanese and Filipino officers and crew, both in raising the alarm when the fire was discovered and in communication between the ship's staff and the NSW Fire Brigades once the latter had arrived on board.

It is further considered that the NSW Fire Brigades, under very difficult circumstances, successfully fought a fire that had reached a stage where it was well beyond the firefighting resources of the vessel. It was indeed fortunate that Ming Mercy was within reach of shore assistance and also that the pilot launch was nearby, attended the vessel and was able to summon assistance from ashore.

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.