Lesson from grounding: Check rudder angle indicator

SEPTEMBER 23, 2014 — The Australian Transport Safety Board has issued its final report on the October 29, 2013 grounding of the Universal Shipping general cargo ship Bosphorus at Lytton Rocks Reach in the Brisbane River after the ship’s helmsman unintentionally put the helm the wrong way.

By the time that the Brisbane Marine Pilot on board the 11,145 dwt ship realized that the helm had gone the wrong way, it was too late to prevent the ship from grounding in the narrow section of the river.

There were no reported injuries, damage or pollution as a result of the grounding.

The ATSB’s investigation found that the application of incorrect helm was not identified by the ship’s crew and that the ship’s safety management system documentation provided no guidance in relation to the allocation of function based roles and responsibilities to members of the bridge team during pilotage.

The investigation also found that the navigational watch was handed over at a critical point of the pilotage and the risks associated with this change were not considered. Furthermore, neither the ship’s safety management system nor the Brisbane Marine Pilots’ passage plan detailed any guidance or instructions relating to handing over the watch or helmsman during high risk areas of the pilotage.

ATSB says that the Brisbane Marine Pilots have amended their safety management system procedures to address all of the contributing factors specific to pilotage issues detailed in this report. Their risk management team has amended the passage plan specifically related to watch hand overs and changing of the helmsman.

The ATSB says that the safety message from the incident is that, while functional roles and responsibilities should always be clearly assigned to each bridge team member, the pilot, the master and the officer of the watch should all check the rudder angle indicator before and after each helm order.
 
Read the ATSB report HERE