Dec 202010

Masters, of course, are at the pointy end of any sharp stick poking around after an accident and, in some jurisdictions, can be detained for more than a year even when not accused of a criminal act. MAC was, therefore, interested to note a part of the Australian Transport Safety Board’s report into the grounding of the tanker Atlantic Blue at Kirkcaldie Reef, Torres Strait in February, 2009, while under pilotage that does not seem to have it even into the maritime media:

When Atlantic Blue’s master realised that the ship was aground, he stopped the main engine and took action in accordance with the ship’s emergency procedures. He made timely notifications to AMSA, the ship’s managers and other parties ashore. He then provided them with initial and regular updates of damage assessments and related information.

Earlier in the voyage, the master had simulated a notification exercise with AMSA and felt this experience enhanced his response to the grounding. He also thought a number of routine emergency drills conducted on 6 February may have improved the emergency response on board in general.

As is so often the case, unsupported assumptions played a role in the grounding. The second mate assumed that the pilot was aware of the ship’s position and track, he wasn’t. The pilot assumed that the VTS for the reef would alert him if the vessel exited the two-way route it was on but it didn’t and couldn’t. The second mate assumed that a pilot-advised course change was intended to come on to the next course change, it wasn’t.

Among ATSB’s finding:

Contributing safety factors
•At 0130 on 7 February 2009, Atlantic Blue’s heading was altered to 066º (T) and, for more than 1 hour, no allowance was made for the strong wind abaft the port beam or the east-going tidal stream. As a result, the ship moved outside the boundary of the charted two-way route that it was transiting.

•The heading adjustments at 0237, 0246 and 0256, a total of 7 degrees to port, were too small to bring the ship back on track and it progressed about 1 mile south of, and parallel to, its planned track towards Kirkcaldie Reef.

•The alteration of course to port after 0307 was neither early enough nor large enough to avert the grounding.

•The passage plan did not define any off-track limits and the bridge team did not discuss these limits, define roles and responsibilities for track monitoring or use available automatic track monitoring functions to support a shared mental model.

•The position fixing and track monitoring methods used by the bridge team were not consistently accurate. This was a result of not making the most effective and appropriate use of the radar and global positioning system equipment.

•Bridge resource management was ineffective and the state of the bridge progressively declined in the absence of a shared mental model and adequate communication between members of the bridge team.

•At about 0230, the master left the bridge without checking if it was safe to do so by verifying Atlantic Blue’s position. If he had determined that the ship was a mile off-track and outside the two-way route, he probably would have initiated some corrective action and remained on the bridge to monitor the effectiveness of the action taken. As a result, the state of the bridge would not have continued to decline and the ship may have moved closer to the track.

•By not using the pilot’s electronic charting system equipped laptop computer, an available aid to monitor Atlantic Blue’s progress and the additional defence it provided against a grounding was removed.

•Atlantic Blue’s safety management system procedures did not require specific off-track limits to be included in the passage plan or otherwise ensure that limits for effective track monitoring were always defined.

•The pilotage system used by Atlantic Blue’s pilot did not define off-track limits or make effective use of recognised bridge resource management tools in accordance with the Queensland Coastal Pilotage Safety Management Code and regular assessments of his procedures and practices under the code’s check pilot regime conducted over a number of years had not resolved these inconsistencies.

• The ‘shallow water alert’ generated by the Great Barrier Reef and Torres Strait Vessel Traffic Service’s (REEFVTS) monitoring system did not provide adequate warning of Atlantic Blue entering shallow water because the boundary of the defined shallow water alert area was too close to dangers off Kirkcaldie Reef.

•The REEFVTS monitoring system did not provide an ‘exiting corridor alarm’ when Atlantic Blue exited the two-way route that it was transiting because the route had not been defined as a navigational corridor.

Other safety factors
•In the period leading up to the grounding, the performance of Atlantic Blue’s bridge team members could have been affected by the normal decline at that time of the day due to the body’s circadian rhythm. A decrease in the pilot’s performance may also have resulted from reduced stimulation after the ship moved into relatively open and navigationally less challenging waters. The second mate’s reduced sleep and increased working hours may have led to a decline in his task performance.

Other key findings
•Atlantic Blue’s voyage data recorder did not save incident data to any storage drive of its system because, at the time of the grounding, it was not functional. The equipment did not provide a failure indication, as required by international standards, that data had not been saved or backed up nor did it display any error, fault or warning to indicate a defect.

• The actions taken in response to Atlantic Blue’s grounding, both on board the ship and ashore were timely and appropriately managed.

The Australian Maritime Safety Authority (AMSA) has advised the ATSB that a review of the coastal pilotage marine orders is being finalised. Changes will include an upgrade of check pilot procedures to promote more rigour and independence within the check pilot system. It is also intended to enhance pilot training and licence renewal requirements through the use of bridge simulators and additional testing and training requirements for trainee pilot licences. This training will focus on bridge team management, human factors and piloting to a passage plan. The marine orders will require standard passage plans to be employed and a consultative process to develop plans which are acceptable to all pilots is being progressed.

The review into Coastal Pilotage Services in the Torres Strait and Great Barrier Reef by AMSA and the Department of Infrastructure, Transport, Regional Development and Local Government, commenced in July 2008, is being progressed. An independent, full review of the fatigue management plan is also to be completed.

In its response, AMSA also advised that it has concerns that there may be systemic issues that could impact upon the safe operation of coastal pilots and the ability to fully develop a ‘safety culture’. These concerns are based upon reports from pilots raising various issues about safety and certain aspects of pilotage operations.

Download the ATSB Report here

Also relevant:


(registration required)

The Case of the Confused Pilot

The Case Of The Master Touch

The Case of the Foggy Pilot


Australia Tightens Reef Nots

Is Silence The Greatest Pilot Error?

Federal Kivalina Grounding – Bridge Team Lost Control – No Passage Planning

APL Sydney Gas Pipeline Rupture – Comms The Snag

Lessons From Sea Mithril’s Triple Touch On The Trent

NTSB Tells Atlanship “Train Crew In BRM”

Pilot Body Criticised For Failures Post Cosco-Busan

Paying For The Perilous Pilot

InterManager Welcomes New Pilotage Standards


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