Ineffective bridge resource management seen in bulker grounding

Photo: ATSB

The Australian Transport Safety Bureau (ATSB) says, in a just released investigation report, that ineffective bridge resource management contributed to the grounding of a bulk carrier in the Port of Bunbury, Western Australia

The grounding occurred on April 22, 2023 as the 229 meter long, Isle of Man-registered bulk carrier World Diana, managed by OSM Ship Management, was departing Bunbury under the conduct of a harbor pilot, with two tugs assisting.

After being moved off its berth, the ship had to be turned in the swing basin before exiting the harbour.

“This turn was started earlier than planned, reducing the amount of room available,” ATSB Chief Commissioner Angus Mitchell said. “The ship’s speed was then allowed to increase until there was no room to safely turn, and the bow of the ship grounded on a shallow bank to the east of the harbor entrance.”

The ship sustained minor hull damage, but was able to be maneuvered off the bank. Fortunately, there was no pollution reported.

The ATSB’s investigation found bridge resource management during the pilotage was ineffective.

“Bridge resource management is an important part of safe pilotage,” Mitchell said. “Effective use of available resources reduces the chance of single-person errors and minimizes their impact.”

In this case, the report notes, proper use of the available portable pilot unit, effective communication, and active involvement of the World Diana’s bridge team and the tug masters, would have allowed the deviation from the plan to be detected in time to prevent the grounding.

“Specific information and limits for the departure plan were only known to the pilot, which made it difficult for the bridge team to raise concerns during the event,” Mitchell said. “Nevertheless, had the ship’s master – an experienced ship-handler familiar with the ship’s movement characteristics – been actively monitoring the pilotage, the early turn and ship’s increasing headway should have become evident.”

While not found to have contributed to the grounding, in the course of the investigation the ATSB also found the Port of Bunbury had not developed adequate procedures for arrival and departure plans for larger ships berthed on their starboard side alongside berth no. 3.

“This reduced the information available to pilots for these ship movements, and to share with bridge teams and tug masters to ensure a common understanding of how manoeuvring would be conducted,” Mitchell concluded.

• Download the full report HERE