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Concern summary

The concern related to the operator’s management of the fatigue of coastal pilots who operate on the Inner Route along the Great Barrier Reef.

Reporter's deidentified concern

The reporter expressed a safety concern regarding the fatigue management of coastal reef pilots.

The reporter has provided information on a number of instances, in recent times, where different pilots have been allocated to pilot vessels in the Inner Route and Great North East Channel of the Great Barrier Reef, but have not been allocated sufficient rest time between duties in accordance with the Marine Orders Part 54 Issue 5 Provision 58 Fatigue Risk Management Plan.

Named party's response

The ATSB recently completed a review of Great Barrier Reef (GBR) pilotage. We believe all active participants in the GBR pilotage industry; AMSA, pilotage providers and pilots, have responded in a positive manner to the ATSB review’s safety recommendations. Many of the safety issues identified by the ATSB were in fact being addressed by industry participants and were well progressed at the time the ATSB review was initiated.

The ATSB authors failed to disclose in their review that these safety initiatives had been well progressed or even identified.

The ATSB review addressed the issue of pilot fatigue. We consider that we have more than adequately addressed the ATSB review’s safety recommendations, particularly with regards fatigue management. 

In my view, the conduct of the ATSB review was anything but independent; the lead investigator was an ex GBR pilot who obviously harboured misgivings and preconceived views on the conditions that may have existed in GBR pilotage when the ATSB investigator was piloting in the GBR many years earlier.                

The ATSB should be aware that AMSA checks all GBR pilot rest breaks for all vessels piloted in the GBR. While from time to time there have been minor individual fatigue compliance issues, there is no evidence to suggest there is a systemic problem. Our organisation has nothing to hide and for the sake of good order we deem it appropriate to copy in AMSA on this false and mischievous report. We can only conclude the report was lodged by a party seeking some financial gain or competitive advantage.

The most significant challenge facing GBR pilotage and indeed the Australian pilotage industry is the recruitment and the diminishing source of future trainee pilot. The ATSB review of GBR pilotage did not address this most important issue.

Regulator's response

AMSA has identified fatigue as a specific issue with regards to Coastal Piloting.  As such, AMSA has worked with sleep experts in Australia to develop a fatigue risk management plan (FRMP).  AMSA monitors against this plan based on reports when pilots identify to REEFVTS as commencing or ceasing duties.  It is noted that this external regulatory monitoring does not take into account the variable time that a pilot may spend travelling to or from the pilotage location.  To assess the ongoing compliance with the FRMP AMSA conducts audits of the pilotage providers overall Safety Management System.  The SMS must address the elements of Marine Order 54, which includes the obligation on both the pilot provider and the pilot to adhere to the agreed FRMP. 

Based on the REPCON reports AMSA undertook a spot audit of all providers to ensure compliance with the FRMP. 

The compliance audits focussed on compliance with the fatigue risk management aspects of Marine Order 54 (Coastal Pilotage) at the end of May 2014. The audits noted that each pilotage provider has a system in place for fatigue management as part of their Safety Management System.  A spot check of pilot voyages did note some inconsistency in application of the systems, which resulted in some non-compliances with the fatigue risk management plan.  This has resulted in a request for Pilotage Providers to review their safety management systems. Such a review and subsequent implementation of any required changes is to be complete by the end of August with AMSA conducting a follow-up audit in November.

ATSB comment

The ATSB investigates with the sole aim of improving safety. It is not a function of the ATSB to apportion blame or determine liability. ATSB investigations are not the product of an individual. Each investigation is overseen by an investigation team, goes through a through a thorough peer review process and subsequently a review by the team manager, the General Manager and then the Commission. This process ensures that no investigation is significantly biased due to a particular investigator’s background or experiences.

As a result of this REPCON report, the ATSB reassessed the Safety Recommendations MI-2010-011-SR-050 and MI-2010-011-SR-051 which were released in response to the actions taken in relation to Safety Issue MI-2010-011-SI-03.

The results of this assessment were that Recommendation MI-2010-011-SR-051 was closed as all three operators in this area have taken sufficient action to address the issues in the current regulatory environment. Safety Recommendation MI-2010-011-SR-050 is still being monitored as the issue is still being addressed by AMSA.