Safety Issue

A number of the risk controls established by Fremantle Ports to ensure the safe entry of large container vessels were ineffective. These included:

• Inconsistent compliance with designated daylight entry requirements
• Ineffectiveness of the second pilot’s role in monitoring the progress of the pilotage
• Inconsistent procedural documentation and application regarding tug usage
• Inadequate compliance with operational wind limits and non-routine task protocols
• Inadequate information exchange between the VTS and pilots.

While not all contributory, the above factors collectively reduced the effectiveness of the port’s risk control measures and increased the likelihood of a safety occurrence.

Response by Fremantle Port

Fremantle Ports provided the following response in relation to each of the identified risk controls:

1. Inconsistent compliance with designated daylight entry requirements

Daylight entry requirements when ‘turning on arrival’ have been clarified/specified in section 4.1.2.1 of Revision 17 of the Operational Parameters document issued on 8 October 2025. In addition, Fremantle Ports are in the process of conducting validation trials for nighttime ‘turning on arrival’ manoeuvres following the installation of an additional aid to navigation and simulation training of the pilots.

Additionally, Fremantle Ports is in the process of implementing a passage monitoring and auditing software service so as to provide auditing capabilities to identify and rectify outliers and non-compliances prior to them culminating in an incident. This software is also intended to be used as a post-incident investigative tool.

2. Ineffectiveness of the second pilot’s role in monitoring the progress of the pilotage

The role of the secondary pilot during two-pilot jobs shall be re-iterated through a dedicated ‘Harbour Master Instruction’ published after discussion with Fremantle Pilots to add considerations mentioned in Fremantle Pilots procedures and any additional requirements found important.

3. Inconsistent procedural documentation and application regarding tug usage

Tug usage, making fast and release requirements have been stipulated in section 5.4 of Revision 17 of the Operational Parameters document issued on 8 October 2025.

4. Inadequate compliance with operational wind limits and non-routine task protocols

A number of improvements have been implemented and are in the process of being implemented.

• Implemented:
  • improved squall alerts through service provider 'Weatherzone'
  • addition of a virtual wind gauge at Outer Pilot Boarding Ground
  • reduction of wind parameters for LCVs to 15–20 kts
  • reduction of maximum wind speed for vessels 275–310 m to 30 kts from 34 kts.
• Pending implementation - Addition of a fixed wind meteorological station at the Halls Bank beacon to provide decision support regarding prevailing wind conditions prior to the 'abort point'.

5. Inadequate information exchange between the vessel traffic service and pilots.

Training shall be provided to vessel traffic service (VTS) officers towards implementation of a 'Challenge and Response' process within VTS monitoring operations. This shall include the importance of adequate implementation of the risk controls and parameters revised from time to time.

ATSB comment

The ATSB acknowledges the actions taken by Fremantle Ports to address the identified safety issue including implementation of the passage monitoring and auditing software and the review of the existing risk controls and revising certain controls through the latest revision of the Operational Parameters. 

Further, the addition of meteorological tools and squall alerts to aid decision making and the reduction of wind limits for vessel movements are also noted. The ATSB will monitor progress on the implementation of these actions by Fremantle Ports and verify that periodic reviews are conducted to ensure that the risk controls are being complied with.