Marine safety investigations & reports

Collision between the Liberian registered bulk carrier Grand Rodosi and the Australian registered fishing vessel Apollo S in Port Lincoln, SA on 8 October 2010

Investigation number:
Status: Completed
Investigation completed

Safety summary

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What happened

At about 1450 on 8 October 2010, the partially loaded Liberian registered bulk carrier Grand Rodosi collided with the Australian fishing vessel Apollo S in Port Lincoln, South Australia. As a result of the collision, Apollo S, which was unmanned, was crushed against the wharf and sank shortly afterwards. Grand Rodosi sustained several relatively small holes in its bow shell plating.

What the ATSB found

The ATSB investigation found that, despite the pilot ordering astern movements, the ship's main engine did not run astern in the 5 minutes leading up to the collision. The chief engineer, who was operating the main engine start/fuel lever in the engine room control room, did not allow sufficient time for starting air to stop the ahead running engine. Consequently, when fuel was introduced into the engine, it continued to run ahead, despite the astern telegraph orders.

The investigation also found that the chief engineer's mistake was not identified by anyone on the ship's bridge or in the engine room control room until after the collision; that the master/pilot information exchange was less than optimal; and that bridge resource management principles could have been better applied during the passage to the berth.

What has been done as a result

Newlead Bulkers, the ship's managers, have amended their on board procedures to ensure crew monitor the direction of main engine turning after each engine order. They have also increased awareness through their fleet about this type of incident occurring.

Flinders Ports, the provider of pilotage services in Port Lincoln, have revised their risk assessment for the manoeuvre being undertaken during Grand Rodosi's berthing to include new preventative, as well as restorative, measures to be followed. Flinders Ports has also revised the port's pilotage passage plan to include indicative courses to be followed, both while transiting the channel and outside of it, and speed zones. This will enable the crews of visiting ship to be better informed about the pilotage passage their ship is about to undertake.

Safety message

It is of paramount importance that pilots and ships' crews maintain awareness of main engine movements and check engine tachometers following every movement to ensure that the engine is operating in the desired direction. This is particularly important when main engines are being operated in manual control.

In addition, pilots and the bridge teams should ensure that all the necessary information is exchanged at the beginning of a pilotage, including courses to be followed and speeds at critical positions during the passage to or from the berth/anchorage, so that all members involved in the pilotage have a shared mental model and therefore, a good understand of the pilotage before it begins.

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Safety Issues

Go to MO-2010-008-SI-01 - Go to MO-2010-008-SI-02 - Go to MO-2010-008-SI-03 - Go to MO-2010-008-SI-04 - Go to MO-2010-008-SI-05 -

Automatic defences within the ACIII system bypassed

When the main engine was operated in engine room control mode, there was no automatic interlock to prevent ‘wrong way’ operation of the engine and no audible alarm to indicate when it was running the ‘wrong way’. As a result, the only system protections to warn the crew of ‘wrong way’ running of the engine were the bridge and engine control room console mounted flashing light indicators.

Safety issue details
Issue number: MO-2010-008-SI-01
Who it affects: All ship's engineers
Status: Adequately addressed

Flinders Ports passage plan

While the Flinders Ports passage plan for Port Lincoln contained information relating to general navigation in the port, such as depths and navigation/channel marks, it did not contain actual passage specific information, such as courses and speeds to be followed. If the plan had contained course and speed information, the ship’s crew would have been better prepared for the pilotage.

Safety issue details
Issue number: MO-2010-008-SI-02
Who it affects: All pilotage organisations
Status: Adequately addressed

Risk assessment and contingencies for manoeuvre

Flinders Ports had not undertaken a risk assessment, or developed contingency plans for this specific shiphandling manoeuvre in Port Lincoln. Consequently, the pilot had no guidance regarding what actions to take if the berthing manoeuvre did not progress as he planned.

Safety issue details
Issue number: MO-2010-008-SI-03
Who it affects: All pilotage organisations
Status: Adequately addressed

Procedures for ACIII bridge control system

Newlead Bulkers had not implemented any procedures or guidance to inform the crew that extra vigilance was required when operating the main engine in engine room control mode because there was no automatic interlock to prevent ‘wrong way’ operation of the engine and no audible alarm to indicate when it was running the ‘wrong way’.

Safety issue details
Issue number: MO-2010-008-SI-04
Who it affects: All ship owners, operators and managers
Status: Adequately addressed

Tug masters participation

The participation of the two tug masters in the pilotage process was not actively encouraged in Port Lincoln. Consequently, it was not until after the collision that one of the tug masters advised the pilot that the ship's main engine was still running ahead.

Safety issue details
Issue number: MO-2010-008-SI-05
Who it affects: All pilotage organisations
Status: Adequately addressed
General details
Date: 08 October 2010   Investigation status: Completed  
Time: 1448 (UTC +10 1/2)   Investigation level: Systemic - click for an explanation of investigation levels  
Location   (show map): Port Lincoln    
State: South Australia    
Release date: 13 September 2012   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Vessel 1 details

Vessel 1 details
Vessel Grand Rodosi  
Flag Liberia  
IMO 8800327  
Type of operation Bulk carrier  
Damage to vessel Minor  
Departure time Port Lincoln, SA  

Vessel 2 details

Vessel 2 details
Vessel Apollo S  
Flag Australia  
IMO 0634  
Type of operation Steel fishing vessel  
Damage to vessel Destroyed  
Last update 03 April 2020