Generic Safety System Led to Gas Carrier’s Blackout Maneuvering in Brisbane

 

The use of a generic safety management system and a lack of adequate controls to manage risk led to a potentially dangerous blackout and loss of control as a vessel was maneuvering at the Port of Brisbane earlier this year, reports the Australian Transport Safety Board (ATSB). While fast actions by the pilot and a tug averted the danger, the incident highlights the importance of detailed safety management systems and procedures for vessels.

The ATSB report details an incident with the Liberian-flagged gas carrier Gaschem Homer (3,895 dwt) as it was departing the Port of Brisbane on March 15, 2025. The vessel, which had a crew of 15 aboard, arrived at the port the prior day to offload a cargo of propane and butane gas. Built in 2021, the vessel is 100 meters (328-feet) in length.

During the offloading operation, all three of the vessel’s generators were operating, but after completion, the electrical demand was reduced, and two generators were shut down. At 1000 on the morning of the 15th, the engine room received a one-hour departure notice from the bridge. The two generators were started, placed in automatic mode for synchronization, and then placed in manual mode and allowed to warm up under low load. The engineers then proceeded with the other pre-departure checklist tasks.

A tug came alongside at 1047, and the vessel dropped its final line at 1059 to prepare for departure. The pilot instructed the master to start the bow thrusters to aid the vessel’s swing from the pier into the channel. Four minutes later, as the vessel was about a third of the way through its swing, the ship blacked out, losing all electrical power, propulsion, and steering.

The pilot reacted quickly, ordering the tug to aid in keeping the ship in the channel while the crew started the emergency generator. They were also standing by the anchors. The main engine was restored in about two minutes, but by that time the ship had nearly completed its swing into the river. Unsure of the cause, the pilot retained the tug until the ship was near the mouth of the river.

ATSB determined in its report that when the bow thrusters were engaged, it tripped an overload on one of the generators. Secondary power failure alarms had sounded on the other two generators. A review of the settings showed that only one generator was on automatic, and the other two had never been switched from manual to automatic. With only one generator engaged, the ship did not have sufficient power for the trusters.

“In this serious incident, the pre-departure checklist was purposed as a substitute for a detailed procedure, but provided little in the way of specific and usable task descriptions,” said Chief Commissioner Angus Mitchell. “Consequently, the crew had to rely on memory and experience to complete critical tasks, which increased the likelihood of an oversight.”

The safety management system had generic engine room operational procedures for the company’s fleet. It did not consider the specifics of the vessel and its systems, and did not provide adequate controls to manage the risks, concludes ATSB.

They point out that while there were no injuries or damage in this incident, the loss of propulsion and steering in a confined space, such as the port, was a serious incident. Also, in this case, the vessel had offloaded its dangerous cargo, which, if aboard, would have further increased the potential of a serious event.

The ship’s manager conducted a risk assessment and established additional controls for the management of its ships. It amended its shipboard safety management system, updated the pre-departure and arrival checklists, and developed a power demand matrix. Targeted training was also undertaken for the engineers on critical power management and monitoring tasks.

ATSB reports that management addressed the safety issues. It, however, warns other operators, saying this demonstrates the importance of having ship-specific procedures and identifying the risks associated with shipboard operations and critical equipment.