International

Executive summary

Overview

On 23 September 1999, at about 2247 local time, a Qantas Boeing 747-438 aircraft registered VH-OJH (callsign Qantas One) overran runway 21 Left (21L) while landing at Bangkok International Airport, Thailand. The overrun occurred after the aircraft landed long and aquaplaned on a runway which was affected by water following very heavy rain. The aircraft sustained substantial damage during the overrun. None of the three flight crew, 16 cabin crew or 391 passengers reported any serious injuries. 

The Aircraft Accident Investigation Committee of Thailand delegated the investigation to the Australian Transport Safety Bureau (ATSB) on 18 November 1999. In accordance with this delegation, the ATSB conducted the investigation according to the standards and recommended practices of Annex 13 to the Convention on International Civil Aviation and the Australian Air Navigation Act 1920, Part 2A. 

In terms of overall accident statistics, runway overruns are a relatively common event. Of the 49 accidents involving western-built high-capacity jet aircraft reported during 1999, 11 were landing overruns. Landing overruns typically occur when the runway is wet or contaminated and/or the aircraft is high and fast during final approach.

The accident flight (see part 1) 

The first officer was the handling pilot for the flight. The crew elected to use flaps 25 and idle reverse as the configuration for the approach and landing, in accordance with normal company practice (since December 1996). 

At various stages during the approach to runway 21L, the crew were informed by air traffic control that there was a thunderstorm and heavy rain at the airport, and that visibility was 4 km (or greater). At 2240, a special weather observation taken at Bangkok airport noted visibility as 1,500 m and the runway visual range (RVR) for runway 21 Right (21R) as 750 m. 

The Qantas One crew was not made aware of this information, or the fact that another aircraft (callsign Qantas 15) had gone around from final approach at 2243:26. At 2244:53, the tower controller advised that the runway was wet and that a preceding aircraft (which landed at approximately 2240) reported that braking action was ‘good’. The Qantas One crew noted no effect from the weather until visibility reduced when the aircraft entered very heavy rain as it descended through 200 ft on late final approach. The aircraft then started to deviate above the 3.15 degree glideslope, passing over the runway threshold at 169 kts at a height of 76 ft. Those parameters were within company limits. (The target speed for the final approach was 154 kts, and the ideal threshold crossing height was 44 ft.) 

When the aircraft was approximately 10 ft above the runway, the captain instructed the first officer to go around. As the first officer advanced the engine thrust levers, the aircraft’s mainwheels touched down (1,002 m along the 3,150 m runway, 636 m beyond the ideal touchdown point). The captain immediately cancelled the go-around by retarding the thrust levers, without announcing his actions. Those events resulted in confusion amongst the other pilots, and contributed to the crew not selecting (or noticing the absence of) reverse thrust during the landing roll. Due to a variety of factors associated with the cancellation of the go-around, the aircraft’s speed did not decrease below the touchdown speed (154 kts) until the aircraft was 1,625 m or halfway down the runway.

The investigation established that, during the landing roll, the aircraft tyres aquaplaned on the water-affected runway. This limited the effectiveness of the wheelbrakes to about one third of that for a dry runway. In such conditions and without reverse thrust, there was no prospect of the crew stopping the aircraft in the runway distance remaining after touchdown. The aircraft overran the 100 m stopway (at the end of the runway) at a speed of 88 kts, before stopping 220 m later with the nose resting on an airport perimeter road. 

The depth of water on the runway when the aircraft landed could not be determined but it was sufficient to allow dynamic aquaplaning to occur (i.e. at least 3 mm). The water build up was the result of heavy rain on the runway in the preceding minutes, and possibly because the runway was ungrooved. 

During the examination of the performance of the aircraft on the runway, it became evident that the flaps 25/idle reverse thrust landing procedure used by the crew (and which was the ‘preferred’ company procedure) was not appropriate for operations on to water-affected runways. The appropriate approach/landing procedure was flaps 30/full reverse thrust. This had the characteristics of a lower approach speed, of being easier to fly in terms of speed control and runway aim point (for most company pilots), and of providing maximum aerodynamic drag after touchdown when the effectiveness of the wheelbrakes could be reduced because of aquaplaning. Had this configuration been used, the overrun would most probably have been avoided. 

As with other company B747-400 pilots, the crew had not been provided with appropriate procedures and training to properly evaluate the potential effect the Bangkok Airport weather conditions might have had on the stopping performance of the aircraft. In particular, they were not sufficiently aware of the potential for aquaplaning and of the importance of reverse thrust as a stopping force on water-affected runways.

Significant active failures 

Significant active failures associated with the accident flight were: 

• The flight crew did not use an adequate risk management strategy for the approach and landing. In particular, they did not consider the potential for the runway to be contaminated by water, and consequently did not identify appropriate options and/or landing configurations to deal with the situation. That error was primarily due to the absence of appropriate company procedures and training. 
• The first officer did not fly the aircraft accurately during the final approach. 
• The captain cancelled the go-around decision by retarding the thrust levers. 
• The flight crew did not select (or notice the absence of) idle reverse thrust. 
• The flight crew did not select (or notice the absence of) full reverse thrust. 
• The runway surface was affected by water. 

Significant inadequate defences 

Significant inadequate defences associated with Qantas Flight Operations Branch activities were: 

• Company-published information, procedures, and flight crew training for landing on water-affected runways were deficient. 
• Flight crew training in evaluating the procedural and configuration options for approach and landing was deficient.

Post-accident events and cabin safety issues (see part 2) 

The main areas of damage to the aircraft were the lower forward fuselage, the nose and right wing landing gear and landing gear bays, and the engines. Numerous cabin fittings dislodged during the accident sequence. As a result of the nose landing gear collapsing rearwards and upwards into the lower fuselage, the cabin passenger address system and the interphone system for communications between the flight deck and the cabin became inoperable. 

No evidence of fire was found during the post-accident examination of the aircraft. 

After the aircraft came to a stop, the flight crew initiated a process of gathering information from the cabin concerning the extent of the aircraft damage. The failure of the passenger address and cabin interphone systems was a major hindrance to the crew’s efforts to assess the situation in the cabin. Some important information regarding the cabin environment and the external condition of the aircraft did not reach the flight crew. In addition, there were gaps in the information available to the flight crew, the possible significance of which was not considered by them in deciding whether or not to keep the passengers on the aircraft. The captain assessed that the appropriate response was to wait for outside assistance and then conduct a precautionary disembarkation, rather than initiate an immediate evacuation. 

Normal radio communications between the aircraft and the control tower were lost for a few minutes after the aircraft came to a stop. Additionally, the aircraft could not be seen from the tower because of the reduced visibility and the emergency response vehicles were restricted to sealed surfaces by the wet conditions. These issues contributed to the emergency response vehicles arriving at the aircraft about 10 minutes after the accident. 

Approximately 20 minutes after the accident, the crew initiated a precautionary disembarkation from the right side of the aircraft using the emergency escape slides. Although the disembarkation was achieved largely without incident, there were arguably sufficient ‘unknowns’ concerning the condition of the aircraft, and possible related hazards, for an earlier evacuation to have been conducted. 

Significant active failures 

Significant active failures associated with the post-accident events were: 

• The cabin interphone and passenger address systems became inoperable (due to impact damage). 
• The flight crew did not consider all relevant issues when deciding not to conduct an immediate evacuation. 
• Some crewmembers did not communicate important information during the emergency period. 

Significant inadequate defences 

Significant inadequate defences associated with Qantas Flight Operations Branch activities were: 

• Procedures and training for flight crew in evaluating whether or not to conduct an emergency evacuation were deficient. 
• Procedures and training for cabin crew in identifying and communicating relevant information during an emergency were deficient

Another significant deficiency involved the aircraft cabin interphone and public address system. The redundancy provided by the normal and alternate cabin interphone and public address systems in B747-400 aircraft was compromised because some components for both systems were co-located in the same relatively damage-prone position in the lower fuselage aft of the nosewheel. Aircraft design standards in the USA and Europe currently contain no requirements for system redundancy in this sense. The report includes a recommendation to the FAA and JAA regarding this deficiency. 

Organisational factors: Qantas (see part 3) 

The ATSB investigation examined the processes of the Qantas Flight Operations Branch for any systemic organisational issues that may have allowed the deficiencies mentioned above to occur. That examination included a detailed review of the company’s introduction of the flaps 25/idle reverse procedure, as well as company procedures and training relating to water-affected runways. The aim of the new procedure was to reduce costs (e.g. brake maintenance, noise levy charges at Sydney Airport, and thrust reverser maintenance) without affecting safety levels. Examination of the project development process revealed that a proper risk assessment of the new procedure was not undertaken, and that other important considerations were overlooked. There were also significant deficiencies in the manner in which the company implemented and evaluated the new procedures. 

Overall, the investigation identified five deficiencies related to the organisational processes of the Qantas Flight Operations Branch:

• The processes for identifying hazards were primarily reactive and informal, rather than proactive and systematic. 
• The processes to assess the risks associated with identified hazards were deficient. 
• The processes to manage the development, introduction and evaluation of changes to operations were deficient. 
• The design of operational procedures and training was over-reliant on the decision making ability of company flight crew and cabin crew and did not place adequate emphasis on structured processes. 
• The management culture was over-reliant on personal experience and did not place adequate emphasis on structured processes, available expertise, management training, and research and development when making strategic decisions. 

Organisational factors: Civil Aviation Safety Authority (see part 4) 

Significant latent failures associated with CASA’s regulatory operations were: 

• The regulations covering contaminated runway operations were deficient. 
• The regulations covering emergency procedures and emergency procedures training were deficient. 
• The surveillance of airline flight operations was deficient. 

In June 1997, CASA began developing a systems-based approach to surveillance because of deficiencies with the previous approach (which focussed on the end products of the aviation system). However, the new system had not reached maturity at the time of the accident. In 1998 and 1999, there were serious shortfalls in CASA’s planned product-based surveillance of Qantas flight operations. However, because of the significant limitations in the effectiveness of product-based audits to identify the type of systemic and organisational deficiencies highlighted during this investigation, it was unlikely that a higher level of surveillance activity would have revealed these deficiencies. 

Safety action 

(see part 5) 

On 5 December 2000, Qantas advised that all deficiencies identified during the investigation and highlighted in this report either had been, or were being, addressed. Qantas Flight Operations Branch had introduced substantial changes and was examining further changes to its management policies and procedures in the following areas: 

• operational training and procedures 
• hazard identification 
• risk assessment 
• change management 
• design of procedures and training programs 
• management decision-making processes 

Some of these changes were in progress in the period before the accident. The ATSB raised a number of safety analysis deficiency notices (SADNs) concerning Qantas operations as a result of the investigation. Four of these SADNs remained open pending advice from the company on the progress of their change activities. 

CASA was also in the process of making substantial changes to its surveillance processes and the Australian aviation safety regulations. Many of these changes were in progress at the time of the accident. The ATSB made four recommendations where it considered that there remained safety matters that were yet to be adequately addressed.

While maintaining flight level (FL) 330, the crew of a Boeing 747 (B747) aircraft monitored the position report from the crew of a Tupulov 154 (Tu154) aircraft. This position report indicated that the Tu154 was estimating position LAJAK at 1907 UTC. The B747 was estimating LAJAK at 1906. Both aircraft were maintaining FL 330.

The crew of the B747 advised air traffic control of the conflict, who directed the crew of the Tu154 to descend to FL 290. The aircraft were vertically separated at LAJAK.

Despite the close proximity of the aircraft, the B747's traffic alert and collision avoidance system (TCAS) did not display the TU154. The crew confirmed with air traffic control that the secondary surveillance radar (SSR) transponder mode C function of the Tu154 was operating correctly. The crew of the B747 reported that their aircraft's TCAS system was functioning correctly and that they were able to monitor aircraft at other stages of the flight.

Investigation revealed that some Eastern Bloc SSR transponders may be selected by the crew to output altitude information in either feet or metres. The investigation was unable to determine if the Tu154 was equipped with this type of transponder.

The operator of the B747 issued an alert to all crews regarding the capability of Eastern Bloc transponders to output altitude information in either feet or metres and if metres was selected the aircraft may not be visible on TCAS.

At the time the Boeing 747-400 departed Los Angeles for Sydney, operational considerations including weather forecasts did not require the carriage of additional fuel to enable flight from overhead Sydney to an alternate airport.

At 0240 EST when the aircraft was approximately 4 hours from Sydney, an amended weather forecast for arrival at Sydney was issued. The forecast indicated that flight crews could be required to divert to an alternate airport. At the time of the amended forecast Noumea and Brisbane were available to the crew as alternate airports.

At 0430 the trend forecast indicated that Brisbane remained suitable as an alternate aerodrome for the flight. Thirty minutes later, when about 1.5 hours from Sydney and after the aircraft could no longer divert to Noumea, an amended forecast indicated that the Brisbane weather was deteriorating and the airport was now not suitable as an alternate airport. The crew proceeded to Sydney where they landed without incident.

Specified minimum weather and visibility conditions are required for aircraft landing in Australia in order to land safely after conducting an instrument approach. The worst weather conditions under which a particular aircraft may land safely are called the landing minima. If a pilot attempts to land in weather that is worse than the landing minima, a safe landing cannot be assured.

Before an aircraft takes off, the crew must satisfy themselves that they are confident that the aircraft will be able to land safely. One of the requirements that must be considered is that the weather will be good enough at the destination for the crew to see enough to be able to land safely. In order to satisfy themselves that the weather is expected to be good enough, they will assess the appropriate weather forecast.

A weather forecast is a prediction of what the weather will be at some point in the future. It is possible that the actual weather on arrival will be close to, but not exactly the same as the forecast weather; the actual weather on arrival could be better or worse than that which had been forecasted. The crew will need to satisfy themselves that the weather will not be worse than the landing minima when they arrive at their destination. Because of the variability between actual and forecast weather conditions, the crew will only assume that a safe landing can be assured at the destination if the weather forecast for the destination is better than the landing minima. A different set of weather criteria are used when the weather conditions at the destination are being assessed from a forecast, instead of from an observation. These weather criteria are called the alternate minima.

If the forecast weather at the destination is worse than the alternate minima for the destination, then the aircraft must carry sufficient fuel to continue from the destination to another airport where the weather is better than the alternate minima for that alternate location. In this way, a crew may attempt to land at a destination, and remain confident that if the weather has deteriorated below the landing minima, they can still safely continue to another airport where a landing would be assured.

Based on the weather report current at the time of their departure from Los Angeles, the crew of the B747 had ensured that the aircraft carried sufficient fuel to enable flight to an airport where a landing could be assured. Prior to the time when Brisbane became unsuitable as an alternate airport the crew had been able to divert to an alternate airport if a landing at Sydney was not assured.

At the time when the aircraft landed at Sydney, the weather was better than the criteria for the landing minima, but worse than the alternate minima.

Summary

At about 0230 on 22 July 1998 a fire broke out in the engine room of the Antarctic research and supply vessel Aurora Australis. The ship was about 1300 miles south of Tasmania with 54 special purpose personnel (or expeditioners), 24 crew and an ice pilot on board.

About 25 minutes before the outbreak of the fire, the duty engineer had been woken by an alarm on the unmanned machinery space monitoring panel in his cabin. He went to the machinery control room and inspected the engine room. He cancelled the alarm and returned to his cabin at 0213. At that time, everything in the engine room appeared to be normal.

The duty engineer was roused again at 0225 by another alarm and, returning to the engine room, he discovered a fire at the forward end of the port main engine, around the turbocharger. The engine was stopped and the fire alarms sounded.

The fire at the turbochargers was attacked by engineers using portable extinguishers and apparently extinguished. A few moments later, however, at about 0236, a fireball erupted and the engineers were forced to evacuate the engine room. The expeditioners and crew were mustered on the helicopter deck and the fire teams deployed. Preparations were made for the operation of the fixed fire fighting system protecting the engine room.

The Halon 1301 fixed smothering system was released at 0252.Following the release of the halon gas, a MAYDAY message was transmitted and communications were established through Sydney Maritime Communications Centre.

From 0340 onwards, the engine room was re-entered on a number of occasions using self-contained breathing apparatus.

After consultation with the Tasmanian Fire Service by facsimile, ventilation of the engine room commenced at 1444. At about 1540 the engine room could be entered without breathing apparatus for a full inspection.

Although there was some damage to the port engine and turbochargers, the critical damage was to the electrical wiring of power and control circuits carried in cable trays affected by the fire. There was also some water damage, the result of water freezing in pipes in the Antarctic conditions.

Over the next three days, the ship's crew carried out repairs and 'jury rigged' electrical wiring to restore propulsive power to the starboard engine and electrical power to ancillary equipment.

Aurora Australis arrived back in Hobart on 31 July 1998, under its own power.

Investigation of the fire scene showed that the fuel source was from a split flexible hose between the port engine fuel filters and a length of rigid pipe on the fuel spill line.

It was also found that out of ten halon gas bottles, four had failed to discharge.

Conclusions

These conclusions identify the different factors contributing to the incident and should not be read as apportioning blame or liability to any particular organisation or individual. Based on all the evidence available, the following factors are considered to have contributed to the fire:

• The fire was caused by diesel fuel from a split in the flexible fuel hose in the spill line from the main engine coming into contact with a component of the port engine turbo-chargers, the temperature of which was in excess of the auto-ignition temperature of the fuel.
• Failure of the hose was due to its age and to 'wear and tear'.
• Although recommendations relating to fixed pipework on the engines, contained in the Wrtsil Technical Bulletin 'Safety aspects on and maintenance of fuel supply system of VASA 32' issued three years earlier, were implemented by the company, the recommendations in the same bulletin relating to the fitting, care and maintenance of sheathed hoses in the low pressure fuel system, were not followed.
• When fitting the flexible fuel hoses at some time between 1991 and 1992, the ship's drawings were not altered to show the modification to the system.
• Consultations between the company and Lloyd's Register, and the company and Wrtsil, on the use of flexible hoses were 'ad hoc' and no record of consultation or approval concerning their fitting was made by any party.
• No approval was sought from the Australian Maritime Safety Authority for the fitting of flexible hoses.
• Knowledge that the flexible hoses had been fitted under the floor plates was lost with the turn-over of engineers.
• The fact that other flexible hoses were fitted to the engines was well evident, but this did not alert either class or AMSA surveyors to the fact that the modifications were not approved.

It is also considered that:

• In general the response to the fire by the ship's crew and the expeditioners on board was measured, effective, demonstrated initiative and reflects great credit to all on board. Entry into any area adjacent to a fire, however, alone and without breathing apparatus or backup, is extremely hazardous and could compromise an entire firefighting effort.
• The poor design of the electrical operating system for the Halon 1301 fixed smothering system led to its unreliable operation and to the partial discharge, only, of the halon.
• The maintenance of the halon system involved at least three contractors and ship's staff, leading to a lack of continuity in maintenance and probably to the fitting of inappropriate fuses in the 24 volt supplies to the main control units.
• Those involved in restoring propulsion to the ship showed considerable ingenuity, skill and initiative.

Local safety action

The operator issued a standing instruction to all crews reminding them to ensure that company procedures were adhered to when communicating to air traffic control via the CPDLC.

Bureau of Air Safety Investigation safety action

As a result of this and similar occurrences, the Bureau of Air Safety Investigation is investigating a perceived safety deficiency. The deficiency relates to the use of controller pilot datalink communication (CPDLC) messages by air traffic control and pilots for the exchange of operational information.

Any safety output issued as a result of this analysis will be published in the Bureau's Quarterly Safety Deficiency Report.

As a result of this and other similar occurrences, the Bureau of Air Safety Investigation is currently investigating two perceived safety deficiencies. The deficiencies relate to training requirements for air traffic service officers as a result of changes in airspace and the operation of controller pilot datalink facilities by air traffic service officers.

Any safety output issued as a result of these analyses will be published in the Bureau's Quarterly Safety Deficiency Report.

Local safety action

As a result of the occurrence and the subsequent investigations by the Bureau of Air Safety Investigation and Airservices Australia, the Northern District En Route manager implemented the following safety actions:

1. Establishment of a local training assessment panel for non-ab initio controllers transferring inter-group.
2. Establishment of controller pilot datalink facility fault reporting and monitoring procedures.
3. Establishment of monthly meetings to monitor the performance of the SITA (Societe Internationale de Telecommunications Aeronautiques, communications network) controller pilot datalink.
4. Review and amendment of controller pilot datalink controller operating procedures.
5. Provision of sufficient staff to enable rostering of three team leaders.
6. Completion of an audit of operating procedures with a view to standardising flight progress strip marking in the group.
7. Review of the sector 8 (procedural) training course and initiation of action to amend documents and to re-introduce computer-based training for some elements of the course.

As a result of this investigation, the Bureau of Air Safety Investigation issued two safety recommendations regarding the regulation and use of seatbelts by passengers:

IR980222 was issued to the Civil Aviation Safety Authority, recommending that a regulatory requirement be developed for passengers to wear seatbelts at all times when seated.

IR980223 was issued to all Australian airlines, recommending that they introduce a company requirement for passengers to wear seatbelts at all times when seated.

Summary

Early on the morning of 1 November 1997, the Singaporean flag container ship NOL Amber embarked a licensed coastal pilot to the south-west of Booby Island, for the passage through Torres Strait and the Inner Two-way Route of the Great Barrier Reef. The vessel was at maximum draught, 12.2 m even keel, for the passage.

After boarding, the Pilot explained to the Master that there was a two-hour tidal window for negotiating Varzin Passage and that the vessel would then have to 'lose' about one and a half hours between Varzin Passage and Prince of Wales Channel, before there would be sufficient water in Prince of Wales to maintain the stipulated minimum under-keel clearance.

Proceeding at slow ahead, NOL Amber cleared Varzin Passage at 0640 and continued, at slow speed, towards the start of the delineated two-way route off Goods Island. The Pilot informed the Master that the earliest time for entry was 0900 and that he would therefore be turning the ship around to head west. The Third Mate maintained a plot of the ship's progress and a helmsman was on the wheel.

At about 0725, the Pilot gave a helm order to start the intended turn to starboard. At 0735, the ship was called by the Duty Officer at the REEFCENTRE and informed that his radar indicated NOL Amber was heading for shallow water. The Pilot replied that he was turning the ship around, to waste time and that 'they were doing all right', but at 0738 the vessel grounded on Larpent Bank.

Immediate attempts to refloat the vessel were unsuccessful, as were the attempts on the next two high tides. However, after discharging most of the ballast, the vessel was refloated, with the assistance of two local vessels, on 4 November. There was no pollution, the vessel suffered minimal damage and was permitted to resume its voyage after an inspection by divers.

Conclusions

These conclusions identify the different factors contributing to the incident and should not be read as apportioning blame or liability to any particular organisation or individual. The following factors are considered to have contributed to the grounding:

1. The Pilot did not have a properly prepared plan for the necessary delay between Varzin Passage and Prince of Wales Channel, including the turning about manoeuvre.
2. The vessel's Bridge Team had not prepared a proper passage plan, identifying limiting bearings and safety distances.
3. The Pilot did not fully brief the Master and Third Mate on the manoeuvre, to enable them to operate as a fully integrated, supportive team.
4. The Pilot did not ascertain the vessel's position immediately before starting the manoeuvre.
5. The Pilot did not fully evaluate the situation regarding River Embley before deciding which way to turn the vessel.
6. At the start of the turn, the Master did not satisfy himself that the vessel had sufficient room in which to carry out the manoeuvre.
7. At the start of the turn, the Third Mate did not advise the Pilot on the distance off Larpent Bank.
8. Neither the Pilot nor the Master instructed the Third Mate to keep them informed about the distance off Larpent Bank during the turn.
9. The 0735 position was incorrect.

Summary

Late on the evening of 10 June 1997, the Egyptian bulk carrier Thebes, on a ballast passage from Singapore to Newcastle, NSW, embarked a licensed coastal pilot to the north-west of Booby Island for the passage through Torres Strait and the Inner Two-way Route of the Great Barrier Reef.

At about 2345, after negotiating Gannet Passage and with the vessel steadied on a course with Goods Island light right ahead, steering was changed from manual to automatic steering mode. The Pilot then handed the con back to the Master, in order to go below for a few minutes, but before leaving the bridge, at about 2352, he explained his passage plan, on the chart, for the Torres Strait.

When the Pilot returned to the bridge at 0002, the Master and watch officers were at the chart table. Moving through to the wheelhouse, the Pilot initially could not see Goods Island light ahead, but seeing the heading was on 110, he then saw the light wide on the port bow. At the same time, the Master's attention was brought to the 2400 position on the chart, which was well to the south of the track. The Master ran to the steering console and the rudder was put hard to port. However, after turning through about 70, Thebes ran aground on the south side of Larpent Bank.

The engine was put to full astern, water ballast was dumped from the forward upper wing tanks and pumped from the forepeak, and the vessel refloated at 0112 on 11 June. Soundings indicated that no tanks had been breached, therefore passage was resumed.

No pollution or significant damage to the vessel occurred as a result of the grounding and no-one was injured.

Conclusions

These conclusions identify the different factors contributing to the incident and should not be read as apportioning blame or liability to any particular organisation or individual. Thebes grounded after it had deviated from the intended course, the deviation going unnoticed by the ship's bridge team for a period of almost 15 minutes. The following factors are considered to have contributed to the grounding:

1. An error in the setting of the selector switch when changing from manual to autopilot steering modes.
2. During the period the Master had the conduct of the vessel, while the Pilot was absent from the bridge, all officers remained in the chart area and the vessel's progress was not monitored.
3. The spontaneous and simultaneous reactions of the Master and the Pilot to go hard to port, towards the intended track, before a full appraisal of the situation was carried out.
4. The lack of Bridge Resource Management procedures on board, which resulted in the wheelhouse being unattended, the vessel's progress not being monitored and the order to go hard to port not being challenged by the Officer of the Watch.
5. The design of the steering console is such that the setting of the selector switch is not readily discernible, particularly to someone of medium or small stature and at night cannot be readily seen at all. It is further considered that it was reasonable for the pilot to have absented himself from the bridge at that particular time.