Marine safety investigations & reports

Grounding of Bow Singapore, Port Phillip Bay, Victoria on 19 August 2016

Investigation number:
Status: Completed
Investigation completed

Final Report

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What happened

On 19 August 2016 at 1458, a Port Phillip Sea Pilot boarded Bow Singapore outside Port Phillip, Victoria. The pilot was to conduct the ship through The Rip and the South Channel to an anchorage in the northern part of Port Phillip.

At 1614, as the ship neared the eastern end of the South Channel, the rudder ceased responding to helm inputs and remained at 5° to port. The ship started swinging towards the edge of the channel. Steering was regained a short time later but, despite the efforts of the pilot, the ship grounded at 1617.

On 20 August at 0040, Bow Singapore was re-floated, with the assistance of the rising tide and a tug. The ship proceeded to anchor and, later, to the discharge berth in Geelong. After discharging cargo the hull was inspected by divers and no damage was found.

What the ATSB found

The ATSB found Bow Singapore’s steering gear ceased working and the rudder remained at 5° to port. A telemotor solenoid, controlling the rudder’s movement to starboard, had stopped responding to electrical signals. This initiated an uncontrolled turn towards the edge of the channel and shallow water.

The company’s procedures for a steering gear failure required a change in operation from the bridge to local emergency operation from the steering gear room. However, the procedures did not include the steps to be taken on the bridge prior to that change, such as using non follow-up mode and changing to alternate telemotor and/or pump systems.

The planned maintenance system for the steering gear did not include or contain any schedules for any detailed inspections or scheduled parts replacement. In addition, the hydraulic system port and starboard solenoids were painted green and red respectively, to match the side of the ship that each is on when mounted on the shuttle valve. However, this was opposite to the direction the rudder would move when they were operated.

What's been done as a result

Odfjell Management, the ship’s managers, arranged for a manufacturer’s representative of the steering gear to attend the ship when it arrived in Singapore. The solenoids and shuttle valves for both steering systems were replaced, the relief valves were opened and examined and the oil was changed. No faults that could cause the failure were found.

The ship managers have now included a 6‑monthly job entry into their planned maintenance system for the opening and inspection of the steering gear’s solenoids. In addition, the telemotor solenoids have been repainted so that the colours now match the direction of rudder movement, rather than the side of the ship on which they are mounted.

Further, the fleet wide safety management system procedure for ‘steering gear failure’ has been amended to include reference to ship specific emergency change over procedures.

Safety message

For equipment, particularly that which is critical to the safe operation of a ship, it is important that there is a well-formulated maintenance plan that includes inspection, testing and planned maintenance.

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The occurrence

Safety analysis


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Safety Issue

Go to MO-2016-005-SI-01 -

Steering gear planned maintenance instructions

Bow Singapore’s planned maintenance system for the steering gear did not include or contain any schedules for detailed inspections or parts replacement.

Safety issue details
Issue number: MO-2016-005-SI-01
Who it affects: All workers on ships managed by Odfjell Management
Status: Adequately addressed
General details
Date: 19 August 2016   Investigation status: Completed  
Time: 16:17 (UTC +10)   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): Port Phillip Bay    
State: Victoria    
Release date: 05 October 2017   Occurrence category: Serious Incident  
Report status: Final   Highest injury level: None  

Vessel details

Vessel details
Operator Odfjell Management, Norway  
Vessel Bow Singapore  
Flag Singapore  
IMO 9288590  
Sector Tanker  
Type of operation Transit under pilotage  
Damage to vessel Nil  
Departure point Risdon, Tasmania  
Destination Geelong, Victoria  
Last update 14 November 2018