Marine safety investigations & reports

Collision between Royal Pescadores and Da Heng Shan at anchor, Gage Roads Anchorage, Fremantle, WA on 8 May 2014

Investigation number:
Status: Completed
Investigation completed

Final Report

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What happened

At some time before 0530 on 8 May 2014, in adverse weather conditions at Fremantle anchorage, the securing pin worked free from Royal Pescadores’ port anchor chain cable stopper bar. The bar then opened and the windlass brake took the cable load. The brake did not hold and the cable ran out to its bitter end.

At about 0535, the securing arrangement of the bitter end gave way and the entire anchor cable was lost into the sea. With the anchor no longer holding it, the ship turned beam on to the wind and drifted towards Da Heng Shan anchored nearby.

At 0548, Royal Pescadores’ stern collided with the bow of the other ship. Shortly after 0550, Royal Pescadores’ main engine was started and it was manoeuvred clear. Both ships suffered minor collision damage.

What the ATSB found

The ATSB found that the poor condition of Royal Pescadores’ anchoring equipment was indicative of inadequate maintenance. As routine rounds to check the anchor cable had not been undertaken, no one detected the cable stopper’s securing pin as it worked free. Further, the ship’s main engine was not in an appropriate state of readiness for the adverse weather conditions forecast.

Although not contributing to the collision, Royal Pescadores’ anchor cable bitter end securing arrangement was not in accordance with the recognised and recommended design that would allow it to be slipped from outside the chain locker.

The investigation also identified that Fremantle vessel traffic service’s (VTS) precautionary measures for adverse weather conditions were triggered by Bureau of Meteorology (BoM) issued weather warnings. The VTS procedures contained no mechanism to trigger those measures in response to local wind speed conditions. As a result, there was a delay in implementing the measures in deteriorating weather conditions on 8 May.

What's been done as a result

Royal Pescadores manager advised the ATSB that it has taken safety action to improve the implementation of its shipboard safety management system (SMS). The action includes measures to improve crew familiarisation with the SMS, greater company oversight of planned shipboard maintenance, and highlighting the incident to ships in its fleet through a safety circular.

The ship’s managers also advised that all post-2013 built ships in its fleet are equipped with bitter end release arrangements in accordance with the recognised design recommendations. Further, the company intends to ensure this recommendation is applied to ships that it builds in the future.

Fremantle VTS has revised its weather-related procedures with the aim of ensuring that defined wind speed limits trigger precautionary measures. A range of new equipment and appropriate training for operators complements the revised procedures.

Safety message

Weather conditions associated with high wind speeds expose ships at anchor to the risk of dragging anchor and damage to anchoring equipment, and can result in grounding or collision. Therefore, it is imperative that the masters of ships take all necessary precautions to avoid such serious incidents. In waters covered by a vessel traffic service (VTS), the VTS can assist masters in managing those risks by providing weather and other relevant information.

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The occurrence


Safety Analysis


Safety issues and actions

Sources and submissions



Download Preliminary Report
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Preliminary report released 27 August 2014

The occurrence

The information contained in this preliminary report is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from the ongoing investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB's understanding of the accident as outlined in this preliminary report. As such, no analysis or findings are included in this report.

On 28 April 2014, the 148 m geared bulk carrier Royal Pescadores (Figure 1) anchored at Kwinana ‘No 5’ anchorage, about 4 miles from Fremantle Port (Figure 2). While at anchor, the ship’s cargo holds were surveyed and found to be unfit for the carriage of its next cargo.

Figure 1: Royal Pescadore

Royal Pescadores
Source: ATSB

At about 1755[1] on 30 April, Royal Pescadores anchor was weighed and the ship proceeded to a berth in the Fremantle inner harbour. By about 1852, the ship was all fast alongside and, with shore side assistance, the ship’s crew began to descale and clean the holds.

On 2 May, an Australian Maritime Safety Authority (AMSA) surveyor boarded the ship to conduct a Port State Control (PSC) inspection. On completion of the inspection, the surveyor detained the ship because of multiple International Safety Management (ISM) Code deficiencies. All of the deficiencies had to be rectified and re-inspected by an AMSA surveyor before the ship would be permitted to leave port limits.

On 6 May, cleaning of the holds was completed. Fremantle Ports then instructed Royal Pescadores’ master to depart the berth and proceed to Gage Roads ‘A’ Anchorage (Figure 2) while waiting for further loading instructions.

At about 2112, Royal Pescadores was anchored at Gage Roads ‘A’ anchorage and the port anchor was brought up with 6 shackles[2] of cable in the water.

At about 0800 on 7 May, the 106 m asphalt / bitumen tanker Da Heng Shan (Figure 3) anchored in Gage Roads ‘B’ anchorage, about 0.5 miles[3] east of Royal Pescadores.

Figure 2: Gage Roads Anchorage

 Fig2_Cage Roads Anchorage
Source: Australian Hydrographic Service

Figure 3: Da Heng Shan

 fig3_Da heng Shan
Source: ATSB

At about 0300 on 8 May, the Fremantle Vessel Traffic Service (VTS) recorded the weather as stormy conditions with a wind speed of 21 knots from the west-northwest.

At about 0335, a bulk carrieranchored at Gage Roads ‘N2’ anchoragestarted to drag its anchor. VTS advised the ship’s master to weigh anchor and re-position in ‘N2’ anchorage. Later in the morning, the planned inbound pilotage of a ship was cancelled due to the deteriorating weather conditions.

At about 0500, Royal Pescadores port anchor cable began to pay out. However, this was not observed by the officer of the watch (chief mate).

At about 0534, a squall (wind speeds of up to 50 knots) moved through Gage Roads anchorage. The increasing noise from the wind and rain woke Royal Pescadores’ master. He telephoned the bridge and asked about the ship’s position. The chief mate informed him that the ship was holding position.

At about 0535, Da Heng Shan’s officer of the watch (chief mate) observed on the radar that Royal Pescadores was dragging its anchor towards his ship. He tried to contact Royal Pescadores by VHF radio on channels 12 and 16, but received no answer. He then operated the ship’s whistle in an attempt to alert the watchkeeper on board Royal Pescadores, telephoned the ship’s master and operated the general alarm.

Shortly afterwards, Royal Pescadores’ chief mate realised that the ship was dragging its anchor at a speed of about 1.5 knots. He then called the master to inform him. The master immediately went to the bridge and announced over the public address system that all crew should go to their mooring stations. He then told the chief mate to go to the forecastle.

When the chief mate arrived on the forecastle, he saw that the port anchor had been lost. He informed the master and then prepared the starboard anchor for letting go.

Meanwhile, Da Heng Shan’s master ordered his chief mate to proceed to the forecastle and veer[4] more cable out on the starboard anchor.

At 0537, VTS contacted Royal Pescadores to relay Da Heng Shan’s broadcast about its dragging anchor.

At 0540, VTS contacted Royal Pescadores again and asked the master to heave in the anchor immediately and take action to avoid Da Heng Shan. Shortly after, Royal Pescadores’ master contacted VTS to acknowledge the request.

At about 0545, Royal Pescadores’ chief mate let go the starboard anchor.

At about the same time, Da Heng Shan’s main engine was started and the chief mate began to veer more cable on the port anchor. The master used the main engine to sheer[5] the ship to port in an attempt to manoeuvre it away from the approaching Royal Pescadores.

Shortly afterwards, Da Heng Shan’s chief mate retreated from the forecastle as Royal Pescadores closed on the ship’s bow. At 0548, Royal Pescadores’ starboard quarter collided with Da Heng Shan’s bow.

About a minute later, Royal Pescadores’ starboard quarter collided with Da Heng Shan for a second time.

At about 0551, Royal Pescadores’ main engine was started and the master ordered slow ahead. He then began to dredge[6] the starboard anchor, clearing Da Heng Shan.

RoyalPescadores’ master reported to VTS that the ship had lost its port anchor. VTS then advised the master to proceed to an outer anchorage and await further instructions.

At about 0900, Royal Pescadores’ starboard anchor was let go in the Outer Anchorage and the ship was brought up to anchor with 8 shackles of cable in the water.


Royal Pescadores

At the time of the incident Royal Pescadores was registered in Panama, classed with Nippon Kaiji Kyokai (Class NK) and managed by Shih Wei Navigation, China.

The ship was crewed by 20 Chinese and Burmese nationals all of whom were appropriately qualified for the positions they held on board the ship.

The master had 21 years of seagoing experience, of which the last 5 had been in command of this type of ship. He had been on board Royal Pescadores for about 2 months.

Windlass and Anchoring equipment

Royal Pescadores was fitted with two 4.89 tonne stockless anchors, each attached to10 shackles of 54 mm diameter anchor cable.

The bitter end[7] of each anchor cable was secured to the ship by a clench system inside the chain locker. A forged steel fitting was welded to the bulkhead and an anchor cable retaining pin was passed through one side of the fitting through an open cable link of the cable and through the other side of the fitting. A split pin was inserted in the retaining pin to prevent its accidental removal.

The anchor cable passed up the spurling[8] pipe, over the windlass gyspy[9] and through the hawse[10] pipe over the side of the ship (Figure 4).

Figure 4: Royal Pescadores forecastle head anchor and cable arrangement

Figure 4
Source: ATSB

The incident

Sometime between 0500 and 0530 on 8 May 2014, Royal Pescadores’s port anchor windlass cable guillotine bar securing pin worked free and the bar opened. In the prevailing conditions, the windlass brake alone was not sufficient to hold the port anchor in place.

As a result, the anchor cable paid out until it was being held by the bitter end. At about 0535, the bitter end was ripped out as a result of the strain placed on it and the anchor and cable were lost overboard.

With no holding capacity, the ship turned beam on to the wind and began to drift astern at a rate of about 1.5 knots towards Da Heng Shan. At 0548, Royal Pescadores’ starboard quarter collided with Da Heng Shan’s bow.

Investigation activities

The investigation is ongoing and will focus on determining:

  • how the port anchor paid out to the bitter end despite securing arrangements in place
  • the on board maintenance of Royal Pescadores’ anchoring equipment
  • the anchor watch arrangement on board the Royal Pescadores
  • monitoring of the ships position at anchor
  • the role of VTS in the monitoring of ships within port limits during periods of deteriorating weather.

[1]     All times referred to in this report are local time, Coordinated Universal Time (UTC) + 8 hours

[2]     One shackle equals 90 feet or 27.43 m

[3]     A nautical mile of 1,852 m

[4]     To pay out anchor cable under power using the windlass.

[5]     When applied to a vessel at anchor, sheer is the angular movement of the vessel about the hawse pipe point. It can be deliberately produced by applied helm to port or starboard.

[6]     A dredging anchor will hold the bow steady while allowing a ship to move forward or aft. The ship’s pivot point moves to the position of the hawse pipe and, to overcome the anchor’s drag, propulsive power is used giving good steering at low speed. The intention is for the anchor to drag and not to dig in

[7]     The bitter end is the inboard end of the anchor cable that is secured to a strong point.

[8]     The cable passes through the spurling pipe from the windlass to the chain locker.

[9]     The vertical wheel on the windlass which the cable passes over. The cable is held in segments of the wheel known as the snug. The gypsy is held by the clutch plate (when in gear) or by the brake (when about to be let go).

[10]   The section of the ship’s bow through which the anchor cable passes through from the windlass to overboard.

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Safety Issues

Go to MO-2014-003-SI-01 - Go to MO-2014-003-SI-02 - Go to MO-2014-003-SI-03 -

Planned and other maintenance

The poor condition of Royal Pescadores’ anchoring equipment was indicative of inadequate maintenance. The shipboard management team were not aware of the equipment’s maintenance history nor able to provide relevant documents from the ship’s planned maintenance system. 

Safety issue details
Issue number: MO-2014-003-SI-01
Who it affects: All persons charged with maintaining equipment
Status: Adequately addressed

Bitter end securing arrangement

The International Association of Classification Societies (IACS) recommendation for having a means of slipping the anchor cable bitter outside the chain locker had not been provided on board Royal Pescadores. Further, the ship’s classification society, ClassNK, does not consider that the IACS recommended slipping arrangement is necessary for reducing safety risk.

Safety issue details
Issue number: MO-2014-003-SI-02
Who it affects: All persons responsible for ship and crew safety
Status: Partially addressed

Weather related matters

While the Fremantle vessel traffic service (VTS) operational procedures were aimed at having precautionary measures in place for adverse weather conditions, the triggers specified in the procedures only referred to BoM-issued severe weather and gale warnings. As no wind speed limits were specified, the gale force winds experienced at Fremantle throughout the early hours of 8 May did not trigger the VTS procedural responses until 0600 – after the receipt of BoM-issued warnings.

Safety issue details
Issue number: MO-2014-003-SI-03
Who it affects: All ships operating in the Port of Fremantle
Status: Adequately addressed
General details
Date: 08 May 2014   Investigation status: Completed  
Time: 0548 UTC + 8 hours   Investigation level: Systemic - click for an explanation of investigation levels  
Location   (show map): Gage Roads anchorage, Fremantle    
State: Western Australia    
Release date: 13 October 2015   Occurrence category: Serious Incident  
Report status: Final   Highest injury level: None  

Vessel 1 details

Vessel 1 details
Operator Shih Wei Navigation (Taiwan)  
Vessel Royal Pescadores  
Flag Panama  
IMO 9151400  
Sector Bulk carrier  
Type of operation Marine shipboard  
Damage to vessel Minor  
Departure point Surabaya, Indonesia  
Destination Kwinana  

Vessel 2 details

Vessel 2 details
Operator Tianjin Southwest Maritime  
Vessel Da Heng Shan  
Flag Hong Kong  
IMO 9564815  
Sector Tanker  
Type of operation Marine shipboard  
Damage to vessel Minor  
Departure point Singapore  
Destination Fremantle  
Last update 03 April 2020