Safety issue
| Safety issue description |
A number of the risk controls established by Fremantle Ports to ensure the safe entry of large container vessels were ineffective. These included:
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. |
|---|---|
| Issue number | MO-2024-001-SI-01 |
| Issue owner | Fremantle Ports |
| Transport function | Shore operations |
| Issue status | Closed – Adequately addressed |
| Date issue released | 03/11/2025 |
| Issue status justification |
Fremantle Ports has implemented various safety measures and reinforced risk controls to address the safety issue identified by the ATSB. Fremantle Ports has demonstrated:
Collectively, the actions by Fremantle Ports are considered to adequately address the safety issue. |
| Issue finalisation date | 18/09/2026 |
Safety action
| Action type | Proactive action |
|---|---|
| Action number | MO-2024-001-PSA-01 |
| Organisation | Fremantle Ports |
| Action description |
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.
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 response |
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. |
| Action status | Closed |
Organisation response
| Date received | 31/08/2026 |
|---|---|
| Organisation | Fremantle Ports |
| Response text |
On 31 August 2026, Fremantle Ports provided the following update to the various safety actions taken by the organisation in respect of the identified risk controls: 1. Inconsistent compliance with designated daylight entry requirements Further clarifications to daylight entry requirements have been issued via VTS Memo 04-2025 and will also be included in Revision 18 of the Operational Parameters, to be published in December 2026. Implementation of the passage monitoring and auditing software has been completed. The software is used to periodically verify inbound ship transit compliance with daylight entry requirements. 2. Ineffectiveness of the second pilot’s role in monitoring the progress of the pilotage Harbour Master Instruction (HMI) 06-2025, issued on 30 October 2025, reiterated the role of the second pilot during pilotage of LCVs. Compliance with this HMI is being monitored by the harbour master office. 3. Inconsistent procedural documentation and application regarding tug usage The towage procedures are being monitored for effectiveness by Fremantle Ports, with no further changes currently deemed necessary. Fremantle Ports’ passage monitoring software has been used to periodically verify that tugs were made fast to inbound ships before the channel entrance. 4. Inadequate compliance with operational wind limits and non-routine task protocols The following additional initiatives / processes have been implemented:
5. Inadequate information exchange between the vessel traffic service and pilots. Training has been provided to vessel traffic service (VTS) officers in implementing a 'Challenge and Response' process during VTS monitoring operations, with particular reference to the non-compliant risk controls identified by the ATSB. |
| ATSB response |
Fremantle Ports has implemented various safety measures and reinforced risk controls to address the safety issue identified by the ATSB. Fremantle Ports has supplied the following supporting evidence to the ATSB:
Collectively, the actions by Fremantle Ports are considered to adequately address the safety issue. |
| ATSB response date | 18/09/2026 |