Passage Plan Conflict Led to Near Miss

The Australian Transport Safety Bureau (ATSB) has released the final report into the near grounding of the bulk carrier Aquadiva in Newcastle Harbour last year, finding that the ship’s bridge crew had not received the harbor pilot’s passage plan before he boarded and that it was different to their plan. This meant the harbor pilot and the bridge crew did not have a shared understanding of how the ship’s passage was to proceed.

The ship’s route and speeds down the channel were discussed between the pilot and master, but they did not compare the ship’s passage plan with the pilot’s plan. There were some differences in the number and location of waypoints between the two plans, and these differences were not identified and corrected. In addition, the master and pilot exchange did not include details of the passage such as maneuvers through turns, wheel over points, rates of turn, comfort zones and cross track error.

As a result, the bridge crew was unable to effectively monitor the ship’s progress, and when insufficient rudder was applied during its passage through the section of the harbor channel known as The Horse Shoe, the crew did not identify this as an error and intervene. The ship slewed toward the southern edge of the channel and went over the limits of the marked navigation channel. Additional tugs were required to arrest the ship’s movement and return her to the channel to complete safe passage out to sea. 

The ATSB also found that ambiguities in the details of the incident (whether the ship touched bottom or not) led to delays in the reporting of the incident to authorities. These delays meant that evidence available at the time of the incident, such as voyage data recordings, were not collected.

As a result of this incident, the Port Authority implemented pilot training and procedures are to be updated to require the use of portable pilotage units on all pilotages. A project to implement sharing of electronic passages plans is also being undertaken.

Aquadiva’s operator provided targeted training to the ship’s officers. The company also completed an internal investigation and circulated the report and discussed and implemented identified preventive and corrective actions throughout its fleet.