case study 1308
The task:
You are to analyse the below described incident, and write a report that
addresses the following issues:
• Identification of safety issues in the incident;
• The safety lessons that can be learned from actions of the ship’s
crew;
• Identification of any possible breaches of relevant international
conventions and/or Australian legislation;
• Suggest proactive safety action for involving stakeholders in
response to this incident.
The Case:
The grounding of a Panama-flagged vessel on a shoal off the coast
of Townsville
General particulars of the vessel: an ore carrier with 230 m LOA, breadth
of 33.4 m and a depth of 19.1 m. The ship has a DWT of 74,285 tonnes
and its summer draught of 13.862 m. The ship is equipped with standard
navigation equipment according to SOLAS requirements, including two
GPS units, an AIS system unit and two X-band radars, but no electronic
chart facility was installed.
The crew members are experienced and hold qualifications for their
positions in accordance with international requirements. In particular:
• The master had 26 years of experience with 10 years in the
capacity of master. He joined the ship 5 months before the
incident. The master has visited Australian ports before, but this
was his first visit to Townsville.
• The chief mate had 21 years of experience and had been sailing
as chief mate for 3 years. He had just joined the vessel in the
previous port of departure and like the master, he had never
visited Townsville before.
The mates maintained a traditional watchkeeping routine of 4 hours on
and 8 hours off. The third mate kept the 8 to 12 watch, the second mate
kept the 12 to 4 watch and the chief mate kept the 4 to 8 watch. In port,
the chief mate worked additional hours as required for cargo operations
Events preceding the grounding
Nine days before the incident, the vessel arrived at the anchorage off
the port of Townsville in ballast condition and dropped anchor. While
at anchor, the crew carried out routine maintenance tasks and the
officers carried out usual anchor watch duties.
Four days before the incident, the chief officer started spending about
3 hours after each evening watch checking cargo and stability
calculations and compare the results with the calculation from the
loading computer.
The day before the incident
0200
The ship received instructions from harbor VTS about the estimated
pilot boarding time of 0400.
0300
The crew started prepare to get underway. The chief mate went to the
forecastle to oversee the anchor weighing.
0320
Anchor was aweigh. The ship was under way to the pilot boarding
ground.
0330
The chief mate returned to the accommodation and prepare for his
watch.
0400
The chief mate took over the watch from the second mate.
0410
Pilot embarked the ship and joined the bridge team consisting of the
master, chief mate, and helmsman. After exchanging information, the
pilot took over the conduct of the ship and guided her to berth.
0600
The crew prepared to make fast the tugs. The third mate take over the
place of the chief mate as he went to the forward station. The second
mate went to command the aft station.
0615
All tugs made fast. The ship was maneuvered toward her berth.
0720
The ship was all fast, starboard alongside her berth. The chief mate
returned to the ship’s office and prepared for receiving cargo.
0820
Loading started. The third mate and the second mate supervised cargo
operation on deck while the chief mate supervised from the ship’s cargo
control room throughout the day, taking meal breaks when he could.
The ship continued with cargo operation.
The day of the incident
0100
The chief mate left the second mate in charge of loading operation and
went to his cabin to sleep.
0300
The cargo surveyor board the ship and the chief mate was called after
as they were about to conduct final stages of the loading operation.
0540
The ship finished loading. Her draughts were 13.68 m forward and 14.05
m aft.
0610
draught survey finished and the chief mate and the cargo surveyor
discussed necessary cargo calculations and paper work. At 0730, the
surveyor passed on final figures to the terminal and other parties
ashore. The chief mate continued verifying cargo figures and ship
stability calculation until 0900 when he left for breakfast, returning 30
minutes later to complete the paperwork.
1035
Pilot on embarked the vessel. The ship was ready for departure. The
master and the third mate were on the bridge, the chief mate and
second mate were standing by at fore and aft stations respectively.
1043
All tugs made fast.
1054
Vessel under way.
1100
All tugs away
1115
Forward and aft stations were stood down. Anchors still standby for
emergency.
1200
The second mate took over the watch from the third mate. The ship was
navigating with a speed of 10 knots under hand steering. The pilot gave
steering orders while the master kept monitoring the ship.
1220
The chief mate finished lunch and retreat to his cabin to rest, setting
the alarm clock to wake him at 1530 for his watch. He then lied down
on his bed and initially had trouble sleeping but subsequently felt
asleep.
1306
Pilot away.
1330
The ship’s position was fixed using GPS and plotted on the chart,
indicating that the ship was on the intended course of 000(T). The
master ordered full sea speed and the ship commenced her voyage to
the next port of call. The weather was good: calm sea, wind NE 15 knots,
clear visibility, clear sky. The ship then engaged in auto-pilot.
The master then ordered the second mate to adjust the planned route
by bypassing the next course alternation waypoint (from 000(T) to
075(T)), resulting in a new track of 020(T). The new course would rejoin
the 075(T) track 5 miles further east than planned and reduce the
voyage by about 2 miles. The second mate complied and laid the new
course line on the current chart and the next one. The original course
line on both chart was not erased. The second mate also did not enter
the coordinates of the amended waypoints in the GPS unit, however, he
did write them next the amended track on the chart.
(* The GPS installed on the ship was set to indicate bearing and distance
to the next waypoint, the XTE alarm was set for 3 cables, and the
waypoint arrival alarm was set for 2 cables. The radar automatically
displayed the bearing of the next waypoint, fed from the GPS).
1400
The ship continued en-route with her engine at full sea speed, reaching
12 knots. The master handed the conn to the second mate and left the
bridge. The duty seaman remained on the bridge for lookout duties.
1500
The ship’s position was fixed using GPS and plotted on the chart,
indicating the ship was on the intended course.
1530
The ship arrived at the amended course alternation point. The second
mate marked the time on the chart and altered course to 020(T). Soon
after, the GPS unit triggered cross track error alarm indicating the ship
had moved 3 cables off the original 000 (T) course line. The second mate
acknowledged the alarm and continued keeping watch. The GPS unit
and radar continued to display waypoint and cross track error
information relative to the original track.
At the same time, the chief mate awoke in his cabin and started
preparing for his watch, having slept for about 30 minutes.
1550
The chief mate arrived on the bridge and checked the log book and
chart. The second mate noticed that the chief mate seemed tired and
he started explaining to the chief mate about the changes to the passage
plan and the new track of 020 (T) and showed him the next waypoint.
The second mate noted to the chief mate that the amended waypoint
had not been entered in the GPS unit. The chief mate acknowledged
this fact.
1600
The second mate fixed the ship’s position by GPS, plotted on the chart,
handed over the watch to the chief mate, and left the bridge.
The chief mate assessed the situation and estimated that the ship would
arrived at the next waypoint, for the 075 (T) course alternation, at about
1700. He then decided to fix the ship’s position at 1630 and continued
keep watch with the duty seaman.
1630
The chief engineer came to the bridge and asked for the ship’s speed,
which the chief mate replied 12 knots. The chief engineer left the bridge
at 1635. This interrupted the chief mate from fixing the ship’s position
at 1630, so he decided to fix the ship’s position at 1700.
1642
The vessel crossed the next waypoint, where the ship’s track would have
been turned to 075 (T).
1700
The chief mate fixed the ship’s position using GPS and plotted it on the
chart. He realized that the ship had passed the course alternation
waypoint about 20 minutes ago, deviated significantly from the
amended track and entering the “no go area” of shallow water marked
on the chart. He also noticed that the ship’s speed had decreased to
about 8 knots.
The chief mate immediate ordered the lookout seaman to engage hand
steering and alter course to starboard. However, just as hand steering
mode was engaged, the chief mate saw the ship’s speed rapidly decrease
and the ship began to shudder. The starboard helm had no effect and
soon the ship’s speed was close to zero.
In his cabin, the master felt the ship shudder, but assumed that the ship
was altering course.
1705
The ship had come to a shuddering stop and grounded on a heading of
020 (T).
The chief mate called the master and asked him to come to the bridge.
The master hurried to the bridge, where he was informed by the chief
mate that the ship may have ran aground. The master noticed the ship’s
speed was zero and ordered the chief mate to fix the ship’s position
using GPS. The plotted position on the chart confirmed that the ship
had grounded. The charted depth was 9.8 m and it was almost low tide.
1710
The chief engineer and the second mate arrived on the bridge,
suspecting unusual movement of the ship. The master asked the chief
engineer to stop the main engine and send the chief mate forward to let
go an anchor. He also ordered sounding all tanks and water depths
around the ship.
1730
Starboard anchor was let go with 2 shackles in the water.
The sounding confirmed that the ship’s hull was breached, one double
bottom ballast tank was flooded and there was water ingress into other
port side ballast tanks.
Depth sounding around the ship confirmed that she was hard aground.
The master informed the ship’s manager of the incident.
1840
The master reported the grounding to the Australian Maritime Safety
Authority (AMSA).
1900
AMSA issued notices to shipping and notified relevant parties.
0024
An AMSA casualty coordinator, transported by helicopter, boarded the
ship. No sign of oil leaking was detected visually by the helicopter pilot.
Later on, inspection by the casualty coordinator confirmed pollution
from a breached bunker fuel oil tank. Approximately 3 tonnes of bunker
oil was lost overboard. Oil and water also entered the engine room and
the main engine was disabled.
The ship remained aground through the night.
Initial investigations found:
All the ship’s navigation equipment was in working order.
The ship’s safety management system contains provisions for hours of
work and minimum rest period on board, consistent with the
requirements from the STCW Code. The guidance to comply with the
provisions was as follow: “The master is responsible for managing
working hours of all crew
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