Grounding: Single-Person Errors Went Undetected

The Australian Transport Safety Bureau (ATSB) has released its report into the grounding of the Maersk Garonne, highlighting failures in bridge resource management and pilotage planning.

What happened

At 0400 on February 28, 2015, a harbor pilot boarded the container ship Maersk Garonne for its passage into Fremantle’s Inner Harbor, Western Australia. The pilotage generally progressed as intended by the pilot until the ship approached the entrance channel 40 minutes later. At this stage, he became concerned that the assisting harbor tugs would not be at the channel’s entrance before the ship.

The pilot decided to delay entering the channel by taking Maersk Garonne outside (south of) the channel and entering it later. The ship subsequently grounded in charted shallow water. The ship did not suffer any damage and was re-floated on the rising tide about three and a half hours later.

What the ATSB found

The ATSB investigation found that bridge resource management was not effectively implemented on board Maersk Garonne. As a result, the ship’s bridge team was not fully engaged in the pilotage and did not effectively monitor the ship’s passage. While the master retained responsibility for safe navigation of the ship, the harbor pilot was the only person actively focused on the pilotage. Consequently, single-person errors that occurred went undetected or inadequately challenged and uncorrected.

The investigation identified that Fremantle Pilots’ publicly available passage planning guidance for the pilotage was inadequate and was not effectively implemented. Further, Fremantle Pilots’ pilotage procedures did not include abort points or contingency plans for identified risks.

The investigation also found that procedures for tugs to be on station at the entrance to the port, or for their coordinated movement, were not clearly defined.

What has been done

Fremantle Pilots, the port’s pilotage provider, has reviewed and updated its website, procedures and training with respect to pilotage, passage planning and communications. This includes simulator training for emergencies.

Svitzer Australia, the towage provider, has updated its procedures to include defined on-station times for tugs.

Fremantle Ports, the port authority, has advised that it has clarified the role of the vessel traffic service in assisting ship arrivals and berthing.

Maersk Garonne’s managers have issued fleet circulars to emphasize and clarify the roles and responsibilities of the master and ship’s crew during navigation with a pilot on board. The managers have also implemented a fleet-wide program that includes education and auditing to ensure compliance with bridge procedures.

The ATSB report is available here.