Image credit: Brendan Foster
The report found bridge resource management was not effectively implemented, pilotage passage planning guidance was inadequate, and procedures for tugs to be on station were not clearly defined.
The ATSB noted that potentially severe consequences of a pilotage accident means that a low accident rate in the past is not a reliable indicator of safety risk.
The grounding incident occurred on February 28, 2015 as the vessel was entering Fremantle’s Inner Harbour.
A harbour pilot boarded the containership at 0400 for its passage into the harbour.
The ATSB report says the pilotage generally progressed as intended until the ship approached the entrance channel 40 minutes later.
At this stage, the pilot became concerned that the assisting harbour tugs would not be at the channel’s entrance before the ship.
At 0442¾, the pilot decided to delay entering the channel by taking Maersk Garonne outside (south of) the channel and then entering it later.
At 0448, the ship grounded in charted shallow water. The vessel did not suffer any damage and was re-floated on the rising tide about 3½ hours later.
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 harbour 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 co-ordinated movement, were not clearly defined.