Marine safety investigations & reports

Grounding of Maersk Garonne, Fremantle, WA on 28 February 2015

Investigation number:
Status: Completed
Investigation completed

Final Report

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What happened

At 0400 on 28 February 2015, a harbour pilot boarded the container ship Maersk Garonne for its passage into Fremantle’s Inner Harbour. The pilotage generally progressed as intended by the pilot until the ship approached the entrance channel 40 minutes later. At this stage, he became concerned that the assisting harbour tugs would not be at the channel’s entrance before the ship.

At 0442¾, the pilot decided to delay entering the channel by taking Maersk Garonne outside (south of) the channel and entering it later. At 0448, the ship grounded in charted shallow water. The ship did not suffer any damage and was re-floated on the rising tide about 3½ hours later.

What the ATSB found

The ATSB investigation found that bridge resource management was not effectively implemented on board Maersk Garonne. As a result, the ship’s bridge team was not fully engaged in the pilotage and did not effectively monitor the ship’s passage. While the master retained responsibility for safe navigation of the ship, the harbour pilot was the only person actively focused on the pilotage. Consequently, single-person errors that occurred went undetected or inadequately challenged and uncorrected.

The investigation identified that Fremantle Pilots’ publicly available passage planning guidance for the pilotage was inadequate and was not effectively implemented. Further, Fremantle Pilots’ pilotage procedures did not include abort points or contingency plans for identified risks.

The investigation also found that procedures for tugs to be on station at the entrance to the port, or for their co-ordinated movement, were not clearly defined.

What has been done

Fremantle Pilots, the port’s pilotage provider, has reviewed and updated its website, procedures and training with respect to pilotage, passage planning and communications. This includes simulator training for emergencies.

Svitzer Australia, the towage provider, has updated its procedures to include defined on-station times for tugs.

Fremantle Ports, the port authority, has advised that it has clarified the role of the vessel traffic service in assisting ship arrivals and berthing.

The safety actions noted above, together with joint simulator exercises, clarify the roles and responsibilities of all parties with respect to monitoring and management of pilotages. This increases safety margins and reduces the likelihood of a similar incident in the future.

Maersk Garonne’s managers have issued fleet circulars to emphasise and clarify the roles and responsibilities of the master and ship’s crew during navigation with a pilot on board. The managers have also implemented a fleet-wide program that includes education and auditing to ensure compliance with bridge procedures.

Safety message

Comprehensive passage planning that includes risk-assessed contingency planning is vital to safe pilotage and underpins effective bridge resource management. The potentially severe consequences of a pilotage accident means that a low accident rate in the past is not a reliable indicator of safety risk.

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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 21 May 2015

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.

What happened

During the morning of 28 February 2015, Maersk Garonne was under Fremantle marine pilot guidance on entry to the Port of Fremantle, Western Australia. At 0441 the pilot ordered port helm to bring the ship around to enter the port Inner Harbour entrance channel. During the turning manoeuvre, attempts to delay the ship’s arrival at the entrance beacons led to the ship passing south of the channel. At 0448 the ship grounded to the south of channel beacons number 1 and number 2. The ship was refloated at 0824 and taken to anchor.

What the ATSB has found so far

Based on preliminary information provided to the ATSB, it was apparent that the ship’s bridge crew had not been directly and actively engaged with the pilotage as it progressed, and were broadly unaware of the pilotage plan. Procedures had not been enacted and actions not taken to ensure the full bridge resources available to the pilot and master were utilised.

Investigation direction

The investigation is ongoing and will focus on:

  • pilotage procedures, planning and practices, information exchange and contingency planning for Fremantle pilotage
  • the existence, relevance, understanding and implementation of procedures by the pilotage company, port and ship to reduce the risk of grounding
  • bridge team dynamics, resource management and personnel engagement during pilotage
  • the implementation and effectiveness of bridge resource management training.
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Alternate: [Download  DOCX: 628KB]


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Safety Issues

Go to MO-2015-002-SI-01 - Go to MO-2015-002-SI-02 - Go to MO-2015-002-SI-03 - Go to MO-2015-002-SI-04 -

Bridge resource management

Bridge resource management (BRM) was not effectively implemented on board Maersk Garonne. The ship’s passage plan for the pilotage was inadequate, its bridge team members were not actively engaged in the pilotage and they did not effectively monitor the ship’s passage.

Safety issue details
Issue number: MO-2015-002-SI-01
Who it affects: All those responsible for navigation
Status: Adequately addressed

Passage plan

Fremantle Pilots’ publicly available information to assist ships' masters with preparing a berth to berth passage plan was inadequate and ineffectively implemented. The information provided consisted essentially of a list of waypoints, which was routinely not followed.  

Safety issue details
Issue number: MO-2015-002-SI-02
Who it affects: All those responsible for a ship’s safe navigation
Status: Adequately addressed

Contingency planning

Fremantle Pilots’ procedures did not include any contingency plans, including abort points, for risks identified for the pilotage. 

Safety issue details
Issue number: MO-2015-002-SI-03
Who it affects: All those responsible for a ship’s safe navigation
Status: Adequately addressed

Towage procedures

Procedures for harbour tugs to meet inbound ships and for their co-ordinated movement in the Fremantle pilotage area were not clearly defined. On 28 February, inadequate co-ordination of the tugs and ineffective communication between Maersk Garonne’s pilot and the tug masters resulted in both tugs, the second one in particular, being significantly delayed from when they could reasonably have been expected to be on station. 

Safety issue details
Issue number: MO-2015-002-SI-04
Who it affects: All those responsible for navigation
Status: Adequately addressed
General details
Date: 28 February 2015   Investigation status: Completed  
Time: 0447 WST (UTC +8)   Investigation level: Systemic - click for an explanation of investigation levels  
Location   (show map): Fremantle harbour entrance    
State: Western Australia    
Release date: 17 October 2016   Occurrence category: Serious Incident  
Report status: Final   Highest injury level: None  

Vessel details

Vessel details
Operator Moller-Maersk, Denmark  
Vessel Maersk Garonne  
Flag Denmark  
IMO 9235579  
Sector Container  
Type of operation Pilotage  
Damage to vessel Minor  
Departure point Singapore  
Destination Fremantle, WA  
Last update 03 April 2020