MARINE SAFETY INVESTIGATION

REPORT 162

Independent investigation into the groundingof the Malaysian flag container ship

Sudbury Reef, Great Barrier Reef 2 November 2000

Bunga Teratai Satu

Report No 162

Navigation (Marine Casualty) Regulationsinvestigation into the grounding of the

Malaysian flag container shipBunga Teratai Satu

on Sudbury Reef, Great Barrier Reefon 2 November 2000

Issued by the

Australian Transport Safety Bureau

May 2001

ISBN 0 642 20038 6

Investigations into marine casualties occurring within the Commonwealth's jurisdiction areconducted under the provisions of the Navigation (Marine Casualty) Regulations, madepursuant to subsections 425 (1) (ea) and 425 (1AAA) of the Navigation Act 1912. TheRegulations provide discretionary powers to the Inspector to investigate incidents as defined bythe Regulations. Where an investigation is undertaken, the Inspector must submit a report tothe Executive Director of the Australian Transport Safety Bureau (ATSB).

It is ATSB policy to publish such reports in full as an educational tool to increase awareness ofthe causes of marine incidents so as to improve safety at sea and enhance the protection of themarine enviroment.

To increase the value of the safety material presented in this report, readers are encouraged tocopy or reprint the material, in part or in whole, for further distribution, but shouldacknowledge the source. Additional copies of the report can be obtained from:

Inspector of Marine AccidentsAustralian Transport Safety BureauPO Box 967Civic Square 2608 ACT

Phone: 02 6274 60881800 621372

Fax: 02 6274 6699Email: marine@atsb.gov.auInternet address: www.atsb.gov.au

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CONTENTS

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Sources of information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Acknowledgment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Narrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3Bunga Tertai Satu . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3The inner route of the Great Barrier Reef . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4Reefcentre . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4The incident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Events at Reefcentre . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Emergency response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12Refloating . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

Comment and analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15The ship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15The mate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16The grounding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17GPS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18Defences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20Shipboard defences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

Procedures and instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21Bridge resource management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22External defences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

Pilotage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23Lights and beacons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23Reefcentre . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

Reefcentre – Reliability of radar system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28Drugs and alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32Submissions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33Bunga Teratai Satu . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36Figures1. Bunga Teratai Satu . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v2. Bunga Teratai Satu’s passage plan and track . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73. Chart showing plotted passage plan from Bunga Teratai Satu . . . . . . . . . . . . . . . . . . .94. Bunga Teratai Satu’s chart table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .195. Bunga Teratai Satu’s GPS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .196. Diagram showing GPS urgent alarm times . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .207. Bunga Teratai Satu’s track on Sirius . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .268. Bunga Teratai Satu’s events and causal factor chart . . . . . . . . . . . . . . . . . . . . . . . . . .30

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SummaryThe Malaysian flag container ship BungaTeratai Satu sailed from Singapore on 26 October 2000, bound for Sydney via theinner route of the Great Barrier Reef with acargo of 857 containers. A licensed pilotwas embarked to conduct the navigationthrough the inner route between GoodsIsland and Cairns.

At 0554 AEST on 2 November 2000, BungaTeratai Satu disembarked the pilot atYorkeys Knob, off Cairns, at the southernlimit of the compulsory pilotage area.

At 0600, ‘full away’ was rung and the vesselresumed its passage to Sydney on a courseof 120° (true). A programmed way-point, atposition 16° 52.8' S, 146° 02.3' E, wasreached at 0700. At this way-point, thecourse was supposed to be altered to 164°(true) to round Fitzroy Island and take thevessel to the west of Sudbury Reef.However, no course alteration was made.

The ship was reporting under the GreatBarrier Reef Ship Reporting System,REEFREP, administered from Reefcentre,Hay Point. This system requires shipstransiting the inner route to report at certainpositions within the inner route. To helpenforce compliance with pilotage andreporting requirements the normal entrypoints to the inner route are monitored byradar. In the limited areas covered by radar,the system fulfils a secondary, monitoringrole, to improve safe navigation.

Bunga Teratai Satu had been acquired as atarget at Reefcentre when it entered the area

covered by the Green Island radar system atabout 0430. From about 0715 to 0725, theReefcentre operator was attempting to re-establish lost targets on the HammondIsland radar display covering the westernarea of Torres Strait. Just before 0716Bunga Teratai Satu entered the restrictedzone (2 miles off Sudbury Reef) but theReefcentre operator did not notice the alarmmessage as he worked on other tasks.

At about 0723, the ship struck the north endof Sudbury Reef at a speed of over 20 knotson a heading of 120°. It was about 13/4 hoursafter low water and the vessel’s bow rodesome 100 metres onto the reef leaving thestern in approximately 12 metres of water.

Nobody was hurt as a result of thegrounding and no oil or other pollutantescaped from the ship. The groundingresulted in mechanical damage to the reefand the yet-to-be assessed effects of theship’s anti-fouling paint.

The Australian authorities issued detentionorders while the ship’s situation was beingassessed. Bunga Teratai Satu remained faston the reef until it was eventually refloatedwith the aid of tugs at about 0930 on 14 November 2000.

The investigation found that the significantunsafe act that resulted in the grounding wasthe inattention of the mate on watch aboardBunga Teratai Satu, who was distracted byhis wife’s telephone call to their familyoverseas.

However, a number of other contributingfactors led to a breakdown in the defencesand protections that may have prevented theship from grounding.

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Sources ofInformationMaster and crew of Bunga Teratai Satu

Malaysian International ShippingCorporation

The Great Barrier Reef Marine ParkAuthority

Queensland Department of Transport

Telstra Corporation

Australian Maritime Safety Authority

Hydrographic Sciences Australia P/L

Hydrographic Office, Royal AustralianNavy

ReferenceHolden, D., Ross, K., Mansell, J., (2000)The Great Barrier Reef Review of SafetyInitiatives.

AcknowledgmentsThe Inspector gratefully acknowledges thelogistical support provided to the investi-gation by the Regional Harbour Master,Cairns.

Photographs of Bunga Teratai Satu suppliedby The Courier-Mail newspaper, Cairns.

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Narrative

Bunga Teratai SatuBunga Teratai Satu (fig. 1) is a Malaysianflag container vessel owned and operated bythe Malaysian International ShippingCorporation Berhad (MISC), of KualaLumpur. The ship operates a regular servicefrom Port Klang and Singapore to theAustralian ports of Sydney, Burnie andFremantle on an approximate 28 day cycle.

The vessel was built in Okpo, Korea, byDaewoo Heavy Industries Ltd and launchedin 1998. Since building it had beenmaintained in class with Lloyd’s Register as

100 A1 containership with LMC, UMS(unmanned machinery spaces) notations.

Bunga Teratai Satu is 184.07 m in lengthoverall (174.02 m between perpendiculars),has a moulded depth of 15.84 m and amaximum beam of 27.44 m. It has asummer deadweight of 21 642 tonnes at asummer draught of 10.218 m. All accommo-dation and machinery spaces are aft of theforward engine room bulkhead at frame 44.Forward of the engine room are five cellularcargo holds extending for 127 m to thecollision bulkhead at frame 90. The holdsare fitted with fixed cell guides and thevessel is able to carry a maximum of 1725 TEU (twenty foot equivalent units),including 242 refrigerated containers. Thedistance between the collision bulkhead andthe forward perpendicular is 11.2 m; thebulbous bow extends 5.6 m forward of theforward perpendicular.

Bunga Teratai Satu is powered by a 6cylinder, two-stroke, Burmeister & Waintype MC diesel engine of 600 mm bore and2 292 mm stroke. The engine develops 12 260 kW and drives a single shaft with a

fixed-pitch propeller, giving the ship anaverage service speed of 19 knots. Wheneither manoeuvring or on passage, theengine is fuelled by heavy fuel oil, althoughit may be run on diesel fuel if necessary.

Fuel is carried in tanks towards the afterpart of the ship. Heavy fuel oil is carried inno. 4 side tanks between frames 65 and 54(88 m and 112.5 m from forward respec-tively). Heavy fuel is also carried in no. 5double bottom heavy fuel tanks betweenframes 54 and 44 (the engine roombulkhead, 145 m from the bow). The otherside tanks (1,2,3 and 5), the forward deeptank, fore-peak and double bottoms (1,2,3and 4) are dedicated water ballast tanks.

The ship is equipped with the normal rangeof navigation equipment including a JRCGPS receiver, type JLR-6800, and tworadars, both JRC type JMA-9000, thestarboard radar being fitted with ARPA. Thebridge and chart room are combined. At thestarboard after corner of the wheelhouse isthe GMDSS equipment in a partitioned andcurtained area.

At the time of the incident, all ship’scertificates required under internationalshipping conventions were valid. Inaddition, the ship was enrolled in Lloyd’sRegister’s 24-hour Ship EmergencyResponse Service, which provided 24-hourtechnical support in the event of anemergency.

The ship’s complement consisted of themaster, chief engineer, mate and 2nd

engineer, who were Pakistani nationals and27 other officers and ratings, most of whomwere from Malaysia. The exceptions werethe 2nd and 3rd mates who were fromIndonesia, the 4th engineer who was fromBangladesh and the electrician who wasfrom Myanmar. The master, who was thirtyyears of age, had held command for 18 months.

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The mate, who was 46 years of age at thetime of the incident, had a career at seawhich spanned 27 years.

Bunga Teratai Satu, as a containership, isnot required to hold an International SafetyManagement Certificate until July 2002.However, the policy of the owners was tooperate the ship in accordance with the ISMCode and to have appropriate documentationin place on board.

The inner route of the GreatBarrier ReefThe southern extremity of the Great BarrierReef compulsory pilotage area is designatedas 16° 40' S. The inner route, betweenGoods Island in the Torres Strait and thissouthern limit, is about 480 nautical miles inlength1. The area contains stretches ofrelatively narrow fairway with restricteddepths. The inner route is subject to intenseseasonal fishing activity. The route offers asafe passage, sheltered from the seaconditions experienced outside the reef. Thedisembarkation point for pilots, who havenavigated vessels south from Torres Strait, isoff Cairns, about 8 miles south of thesouthern extremity of the compulsorypilotage area.

Before 1 October 1991, pilotage was offeredon a voluntary basis. Since that date,following recognition by the InternationalMaritime Organization of the Great BarrierReef as a ‘Particularly Sensitive Area’, theAustralian Government introducedlegislation through an amendment to theGreat Barrier Reef Marine Park Act, 1975,making pilotage through the inner route(and also Hydrographers Passage)compulsory for ships over 70 m in length.

To further enhance safety in the GreatBarrier Reef a ship reporting system (SRS)for ships over 50 m in length navigatingwithin the Great Barrier Reef was adoptedby the International Maritime Organizationin 1996. This was given effect, as of 1 January 1997, by a mandatory system ofship reporting at predesignated positionsbetween the Torres Strait and CapeTownsend. A ship transiting the inner routebetween Torres Strait and Cairns is requiredto make some ten reports to Reefcentre. Thesystem of radio monitoring is enhanced byremote radar coverage of the major entrancechannels to the inner route. Both radio andradar are monitored from Reefcentre, at HayPoint just south of Mackay.

A radar positioned on Green Island, 13 miles to the north east of Cairns,provides coverage of the Cairns area. With arange of 30-35 nautical miles, its coverageincludes Sudbury Reef, situated eighteenmiles to the south east of Green Island.

ReefcentreThe scheme, REEFREP, is a joint AustralianMaritime Safety Authority/QueenslandTransport initiative, operated by QueenslandTransport from Reefcentre at Hay Point nearMackay.

The purpose of REEFREP is to enhancenavigation safety in the Torres Strait and theinner route of the Great Barrier Reef, therebyminimising the risk of a marine accident andconsequential pollution and damage to themarine environment.2

REEFREP is based on ships reporting byVHF to Reefcentre at designated points inthe approaches to the reef and within theinner route, detailing position and speed andother relevant information. The information

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1 All references to miles refer to nautical miles (1852 m)2 Ausrep and REEFREP (1998) Australian Maritime Safety Authority & Queensland Department of Transport

(Maritime Division)

is entered into a Traffic Information Module(TIM). TIM calculates the ship’s ‘deadreckoning’ (DR)3 position based on thepredesignated routes and advised speed. Theship’s information is updated at everyreporting point (at intervals of about 8hours, dependent on speed). If a ship altersspeed or deviates from its planned route toany significant degree it is required to reportto REEFREP, where the operator amends theinformation in TIM. TIM automaticallycorrelates the information with all otherships in the system and predicts the timethat ships will encounter each other. Thisinformation is relayed to the ships in thescheme.

The VHF information is supplemented by aradar system module (RSM). Radarcoverage is from two sites in Torres Strait(Warraber Island and Hammond Island),Green Island (about 15 miles east-north-eastof Cairns) and Penrith Island. Each sitecovers a radius of about 30 miles, hence theradar coverage is limited in terms of thewhole extent of the inner route.

Radar surveillance is sited to cover the mainentry points of mandatory ship-reportingand also covers the compulsory pilotagearea entry points within the Great BarrierReef, the inner route and HydrographersPassage to:

…assist in the detection of ships entering thesystem and in monitoring their movementwithin the system while in the coverage of theradars. The radar detection of ships enteringthe system will also serve to monitorcompliance with the (mandatory) requirementfor designated ships to make the appropriateVHF reports.4

The high probability that a ship failing toreport, as required by Australian law, will bedetected by the radar system is an effectivedeterrent to any master failing to reportunder the SRS or seeking to avoidembarking a pilot.

There are two displays on the TIM system.One screen, the data entry component,records in text boxes information onindividual ships within the system. It is thisscreen into which the initial ship report isentered and updates are made. The systemalso generates 17 different alert conditions,which are displayed in a text box. Fourteenalert messages are routine and three areurgent (ships entering a restricted area, apilotage area, or crossing a boundary line).

The other screen, Sirius, shows an electronicchart of the inner route, which generates aDR position of all ships in the system. Theoperator can ‘zoom’ to any part of the innerroute to obtain a more detailed picture ofany given area. In the event of an ‘urgentoperator alert’ a text box is generated on theSirius screen in addition to the text messageon the data entry screen.

AMSA is responsible for the operation ofthe radars at Hammond Island, WarraberReef and Penrith Island. QueenslandTransport is responsible for Green Islandradar.

The radar system supplements TIM. Theradar targets of reporting ships are identifiedon the real time radar scan. The radar andTIM targets are ‘fused’5 and the ship’sposition in TIM is then maintained by theradar system, while the ship is under radar

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3 Dead Reckoning Position, a position obtained by applying course and distance made through the water from the last known observed position.

4 Ship Reporting System project document.5 Fusing is the reconciling of the dead reckoning position (DR) with the real time radar position.

coverage. The highest risk area, and the areaof most activity, is Torres Strait.

Arbitrary restricted areas enclose the limitsof the fairways, shallow waters or reefswithin the radar coverage area. Off SudburyReef the restricted zone was set two milesfrom the reef. A ship entering a restrictedarea initiates an alert on the Sirius screen inthe form of a window message:

There is a new alert message

Acceptance of this message triggers an‘urgent alert’ in the alert box on the dataentry screen:

Ship (ship’s name) has entered restricted area(location)

The operator sits at a display of four radardisplays on top of an operational screen, thetwo TIM displays and a VHF communi-cations unit.

Reefcentre also operates as the VesselTraffic System for Hay Point, DalrympleBay, Weipa and other small ports on theCape Peninsular. Two VTS operators work a12 hour shift from 1900-0700 or 0700-1900.One operator is dedicated to the REEFREPsystem for about six hours and one to thePort VTS. The duties are then interchanged.

The incident Bunga Teratai Satu sailed from Singaporeon 26 October, on voyage 407 on its regularservice to Australia, via the inner route ofthe Great Barrier Reef, with Sydneydesignated as the first port of call. The shipwas carrying 857 containers, 551/20 footand 306/40 foot containers. Twelvecontainers were listed as carrying somedangerous goods amounting to some 126 tonnes.

At 03006 on the morning of 1 November theship embarked a pilot, together with atrainee pilot, at Goods Island at the westernapproach to the Prince of Wales Passage inTorres Strait. The ship’s draught for thepassage was 8.3 m forward and 8.49 m aft.The pilotage through the inner route of theGreat Barrier Reef proceeded withoutincident. On suitable occasions, the pilottook rest periods leaving the officer of thewatch in charge of the navigation. Thepassage through the inner route wasanticipated to take between 26 and 27 hours.

At 0400 on the morning of 2 November themate took over the watch from the 2nd mateand the able seaman (AB), on lookout andhelm duties, changed. The ship was aboutten miles north of Low Isles, near thesouthern extremity of the compulsorypilotage area. The ship passed Low Isles at0427. At 0430, about 22 miles north of thepilot ground, the mate gave the engine roomone hour’s notice of readiness to manoeuvre.The ship’s position was plotted at about 15-minute intervals.

At approximately 0500 the master made hisway to the bridge. The pilot, who had beenresting, arrived on the bridge at 0530 andthe AB was instructed to change to handsteering. The pilots disembarked at 0550 atthe pilot boarding ground off Yorkeys Knob,north of Cairns (waypoint 33 in the ship’spassage plan see fig. 2). To make a suitablelee for the disembarkation the ship turned toa heading of 270° (T). Once the pilot boatwas clear the master continued to turn tostarboard to bring the ship to a course of118°(T).

Once the pilots were disembarked themaster instructed the mate to ensure that thepilot ladder was properly stowed and to go

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6 All times are Australian Eastern Standard Time

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Waypoint 34

164º

169º Recommended if any traffic

118º

Waypoint 33

118º

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Position ofgrounding A

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Vessel’s track taken from radar

Passage plan

Figure 2:Bunga Teratai Satu’s

passage plan and track

to the forecastle head and secure the anchorsfor the open sea passage. The master thencalled Reefcentre on VHF and reported thatthe pilots had disembarked and the ship wasproceeding south to Sydney. The responsefrom Reefcentre included information thatthere was no other traffic in his vicinity anda request to keep reporting to Reefcentre asnormal. At 0600 the engine room wasadvised to start working up to full sea speed.

At 0615, shortly before the mate returned tothe bridge, the master plotted the ship’sposition on the chart. At about 0620, thesteering was set on ‘autopilot’ with a courseof 120°(T). When the mate had returned tothe bridge, the master and mate discussedthe high consumption of fresh water and theneed to curtail water consumption for a fewdays. Navigation through the remainder ofthe inner route and the continuingrequirement to report to Reefcentre was alsodiscussed. The master asked the mate to getout the folder containing the instructionsand reporting positions for the passagethrough the Reef. The master subsequentlyplotted the 0630 position on the chart byradar range and bearing. At about 0635 themaster, satisfied that the mate hadfamiliarised himself with the vessel’ssituation and navigation, gave the mate theconduct of the vessel and left the bridge. Hemade his way down to his cabin, where heattempted to find a weather forecast on thetelevision to monitor a low pressure systemoff the coast of New South Wales.

Sunrise had been at 0537. The sky waspartly cloudy, the wind from the north-north-west at about 5 knots and the airtemperature was about 25°C.

At about 0640, the duty AB started cleaningthe bridge. The sun was low in the eastabout 20 degrees on the port bow. Helowered the tinted sun-screens to reduce thedirect glare of the sun. The mate went out

onto the starboard bridge wing and made acall on his mobile telephone. Soonafterwards, at about 0655, the mate returnedto the wheelhouse and called his cabin onthe internal telephone, asking his wife tocome to the bridge. She arrived a fewminutes later and the two of them went outonto the starboard bridge wing beforemaking another call on the mate’s mobiletelephone to his mother-in-law’s house inKarachi.

The mate had developed a practice, ofasking the AB to plot the ship’s positionfrom the GPS every hour when the ship wasin open waters. The AB finished cleaningthe bridge and, at about 0700, he plotted aposition of 16° 53.0' S, 146° 02.4' E on thechart and entered it in the GPS PositionRecord book. (Fig. 3) The position plottedwas adjacent to waypoint 34 on the ship’spassage plan, where the ship’s course wasdue to be altered to 164° off Fitzroy Island.The AB moved to the forward part of thebridge on the centre line. According to theAB, he kept expecting the mate to comeback into the wheelhouse to alter course.But the mate did not re-enter thewheelhouse until about 0715, whereupon heand his wife proceeded to make some coffeeat the sink at the port side of thewheelhouse.

At around 0717, after making coffee, themate went to the chart table and checked the0700 position. He looked over the charttable console and told the AB that he hadmade a mistake in plotting the position.Shortly afterwards he told the AB ‘change tohand steering’. He then asked the AB for theship’s heading to which the AB replied‘120°’, the mate said ‘steer 180°’. The ABhowever, could see a sand cay on the ship’sstarboard bow and, instead of alteringcourse, asked the mate if he was sure that hewanted to turn to 180°, towards the sandcay. He added words to the effect, ‘Chief,

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Figure 3:Chart show

ing plotted passage plan from Bunga Teratai Satu

‘Recomm

ended if any traffic’

can we go over shallow water?’ The matethen responded ‘turn 180° to port’.Confused, the AB did nothing and, secondslater, they felt the ship shuddering as it tookthe ground.

At about 0720, the master had noticed onthe gyro-repeater in his cabin that the shipwas still on a course of 120°. Knowing thatthe course should have been altered to thesouth some time earlier, he left his cabin forthe bridge. He was near the stairwell whenhe felt the ship shudder. He ran up the stairsand arrived on the bridge, where he saw theAB on the wheel, the mate in the centre ofthe bridge and the mate’s wife by the sofa atthe port side of the bridge. The mate said ‘Iam altering course to 180°’. The mastercould see that the vessel was on the reef andthat the telegraph was still on full sea speed.He pulled the telegraph back to ‘stop’ andthen sounded the general alarm and said tothe mate ‘chief, the vessel is aground’. Thetime was recorded in the bridge movementbook as 0721 and on the automatic enginemovement recorder, at 0723. Also at 0723,the main engine lubricating oil low levelalarm sounded as the vessel listed tostarboard.

The ship was aground on the northern endof Sudbury Reef, on a heading of 120° witha starboard list of about 7°. The position ofthe bridge was 16° 57.0' S, 146° 09.4' E. Itwas about 2 hours after low water with apredicted tidal height of about 1.1 m abovedatum.

The master checked the chart and saw thatthe last position had been plotted at 0700.The 2nd and 3rd mates arrived on the bridge,whereupon the master instructed them toconduct soundings of all tanks. At the sametime, he started to look up informationrelating to the company’s emergencyprocedures and then tried to call thecompany’s Emergency Response Centre

(ERC) in Kuala Lumpur, but was unable toget a reply.

At that time, Bunga Teratai Satu had onboard 1211.8 tonnes of heavy fuel oil and94 tonnes of diesel. The 12 20-footcontainers of dangerous goods, amountingto about 126 tonnes, included classes offlammable liquids, toxic substances,corrosive material and other miscellaneousclassified goods, amongst which werepolystyrene beads, alcohol, perfume, foodflavouring, and pesticides. All were stowedcorrectly with the required separation.

At about 0737, while the tanks were beingsounded, the ship received a call fromReefcentre on VHF asking about theirposition, to which the master replied thatthey were aground. The master advisedReefcentre that nobody on board had beeninjured and there had been no pollution.Subsequently he tried to call MISC inSydney but, as there was no answer, he left amessage advising them of the situation. Theemergency procedures advised that, in theevent of not being able to contact thecompany’s ERC, he should call any or all ofthe home telephone numbers of thecompany superintendents and managers.Accordingly, the master called and spoke toone of the superintendents.

During this time, a watch was being kept forany sign of pollution leaking from thevessel. As the tanks were being sounded,reports started to reach the bridge that therewas no indication, so far, of any tankshaving been breached. (Later it wasdetermined that the forepeak tank had beenbreached.)

Soundings of the sea around the shipestablished that the ship was aground fromthe bow to about its mid length. The rudderand propeller were in about 12 m of water.

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The Queensland and Commonwealthauthorities maintained contact with BungaTeratai Satu through Reefcentre. The masterpassed information on the bunker oil carriedon board and other relevant information tothe Australian authorities. Although nobreach of the hull was reported, initial stepswere taken to respond to any possible oilpollution. Detention orders were placed onthe ship by both the Queensland andCommonwealth authorities.

Events at ReefcentreOn 2 November the day operator arrived atReefcentre at about 0645 to takeover thewatch. He was an experienced operator, whohad been with Queensland Transport forsome 14 years and at the Hay Point centrefor 10 of those years.

He examined the hand-over book, in whichno problems were recorded. He looked atthe screen displays and scrolled downthrough the whole system looking for anycomments on ships in the SRS. He was toldby the outgoing operator that the BungaTeratai Satu had just dropped off the pilot atCairns and he noted its position on theGreen Island radar screen as just north ofCape Grafton. Also the Royal AustralianNavy’s survey vessel HMAS Melville wasengaged in survey operations in and aroundGannet Passage, which he could see on theHammond Island Radar display.

There were a number of ships beingmonitored by the TIM system and twoothers about to enter the system. As he tookover the watch a few minutes before 0700the vessel Asian Queen made its first reportapproaching Gannet Passage, en route toBooby Island to embark a pilot for the GreatNorth East Channel.

The initial reporting formalities involvedbetween three and four minutes of VHF

transmission. A few minutes later a localvessel called on VHF reporting itsmovement in the southern part of thecompulsory pilotage area.

The Sirius display was centred on theHammond Island Radar. At about 0711 asecond vessel, Thor Princess, enteringTorres Strait by Gannet Passage, made itsfirst report. This procedure also lasted aboutthree minutes.

The operator then fused the real-time radarinformation of Asian Queen with the DRfrom TIM. He then repeated the procedurefor Thor Princess. These two operationstook about four minutes.

At about 0715 the real time radar echo ofJin Hui, on the eastern side of Torres Straitwas lost, the display reverting to a DRtarget. The operator set about restoring JinHui’s fused target. About four minutes laterthe echo of Asian Queen also reverted toDR, followed soon after by Thor Princess’sdisplay. The operator also restored thesetargets. This took until about 0727. Therewas also regular, continuing, routine VHFtraffic until a lull at about 0732.

At about 0736 the operator noticed an‘urgent’ alert message on the Sirius displaywhich was still centred on the HammondIsland radar area. On checking the TIMinformation screen he saw a message:

Ship Bunga Teratai Satu has entered restricted

area STAGG PATCHES

The operator checked the Green Island radardisplay and selected the Green Island areaon the Sirius display. The normal shippingtracks were shown on the radar. One echowas seen close to Fitzroy Island. Theoperator’s first reaction was that this wasBunga Teratai Satu. But he quickly realisedthat the target was showing a north-bound

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vector and it was probably a tourist craft orfishing vessel.

He then realised that an echo showing novector on the north east corner of SudburyReef, was in fact Bunga Teratai Satu. Atabout 0738 he called the ship and asked forits position. The master, in reply confirmedthat the vessel was aground in position 16° 57.04' S 146° 09.41' E.

At 0748, the operator reported thegrounding to the Queensland Department ofTransport and the Rescue CoordinationCentre, Australia. A little later, the operatorat Reefcentre called Bunga Teratai Satu,requesting information on the quantity offuel on board and also details of anydangerous cargo carried. Additional requestsfrom Reefcentre for information on how thevessel happened to go aground elicited noexplanation.

Bunga Teratai Satu called back toReefcentre advising the operator of thedangerous cargo carried - class 3.2, class3.3, class 6.1, class 8 and class 9. Themaster detailed the types and quantity offuel carried on board. In addition, the masterstated that the ship was only agroundforward, that there was no pollution and thatthere did not appear to be any breach of thehull. The ship also reported the weatherconditions as clear with the wind force 3from the north.

Two officers from the QueenslandDepartment of Transport boarded the shipthat morning to make an initial assessmentof the situation.

Emergency responseThe Queensland Department of TransportEmergency Plan was immediately initiated.The Regional Harbour Master based inCairns took control as the designatedIncident Controller. He was responsible forcoordinating the refloating operation andcontingency planning. While the authoritiesassessed the risk of oil pollution as low, theserious consequences of such pollutionmade the deployment of oil spill responseequipment and support teams a priority. TheNational Plan7 and the Queensland CoastalContingency Action Plan were activated at1046 on 2 November.

Throughout the operation the HarbourMaster liaised with the salvors, a largenumber of interest groups and MISCmanagement.

RefloatingA salvage master and salvage team fromUnited Salvage boarded the ship on 4 November. The vessel’s forward section,forward of frame 60, extended some 100 monto the reef. Aft of frame 60 the ship wasafloat, with the stern in approximately 12 mof water. Over the following dayscalculations were undertaken to assess theship’s ‘ground reaction’8, stability and todevelop a refloating plan. Two independentprograms, the ship’s own stability computerand the salvor’s own program were used tocheck the ship’s stability.

Over the ensuing days, to prepare BungaTeratai Satu for refloating, the ship’s fuelwas transferred within the ship. Ballast wasalso transferred and some ballast water,

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7 The National Plan to Combat Pollution at Sea8 Ground reaction is the function of the pressure exerted by the ship on the ground, equal to the loss of buoyancy due

to stranding.

previously taken on in Australian waters,was pumped to the sea with the permissionof the Australian Quarantine and InspectionService.

After laying ground tackle and using tugsand the ship’s engine Bunga Teratai Satuwas refloated at 0928 on 14 November. Theship was anchored off Fitzroy Island and thehull inspected by divers. Apart from the

forepeak, the ship’s hull remained intactalthough plates were indented and heavilyscored.

Throughout the twelve days aground, nopolluting substance escaped from the ship orthe attendant craft. The mechanical damageto the reef and any longer term effect of theship’s tributyltin-based anti fouling paint isyet to be assessed.

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Comment andanalysis

EvidenceThis report is based on the interviews of themaster, the mate and the duty AB of BungaTeratai Satu, the ship’s GPS, charts, logsand other bridge documents. Informationrelating to the mate’s telephone call toKarachi was obtained from Telstra.

The duty SRS operator at Hay Point wasalso interviewed and system records of theREEFREP data were provided throughHydrographic Sciences Australia. Arecording of the Reefcentre’s radar displayshowed the vessel’s movements betweenYorkeys Knob and Sudbury Reef, and alsothe traffic situation and loss of real-timedata in Torres Strait. This was reviewed atReefcentre and audio tape copies of theradio messages between Bunga Teratai Satuand Reefcentre on 2 November weresupplied by Reefcentre, through QueenslandTransport.

The individual radar displays, the TIMinformation (both electronic chart and textdisplay) and VHF traffic are allindependently recorded and were madeavailable to the investigation. The time baseof the three recordings varied by about threeminutes and the actual times of events couldnot be stated with absolute accuracy, but thesequence of events and time lapse is correct.

Information on the refloating of BungaTeratai Satu was obtained through UnitedSalvage and the Queensland Department ofTransport.

The shipBunga Teratai Satu, together with othervessels in the company, is a regular caller toAustralian ports. The ship presented as awell maintained vessel with a compre-hensive management system.

Since 15 April 1998 the vessel had beensubject to six Port State Control inspections,the last in Port Botany on 8 August 2000.The five inspections prior to 8 August hadeither recorded minor or no deficiencies andthe ship had not been detained. On 8 Augustfour deficiencies were found, three of themsignificant:

- frozen engine room ventilator dampers;

- inability to prove satisfactory operationof the GMDSS system; and

- a blown fuse on a lifeboat davit meantthat the lifeboat could not beimmediately retrieved.

The deficiencies were made good before theship sailed.

On 15 November, after the ship wasrefloated, AMSA surveyors inspected theship under the Port State Control provisionsof the Navigation Act. The inspection wasdescribed by AMSA as ‘very detailed’ andcarried out by ‘two experienced surveyors’.The only deficiency found was a loose doorseal on the forecastle head watertight door,which was required to be rectified at thenext port.

Engine and steering trials were completedbefore leaving the anchorage off FitzroyIsland on 15 November. Bunga Teratai Satusailed via Grafton Passage, taking the routeoutside the Barrier Reef to Sydney, where itarrived on Monday 20 December.

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The mateThe mate went to sea as a cadet in 1973with the Pakistan National ShippingCorporation. He left this company in 1981to sail with a number of companies bothPakistani and foreign.

He obtained a mate’s certificate inSingapore in 1997 and in 1998 he obtaineda master’s certificate. At the time he wasworking with a London-based shippingcompany, but this company reduced the sizeof its fleet. At that time MISC had beenconducting interviews and the companyselected the mate for its container ships,although he was more familiar with bulkcargoes. He had been employed by MISCsince 21 September 1999.

In respect of the mate, his qualification andemployment, MISC submitted that:

…MISC had implemented all procedures undertheir (voluntarily implemented) SafetyManagement System to ensure the chief officer(mate) was suitably qualified and experienced toserve in the rank of chief officer beforeemploying him. The chief officer’s performancewas monitored throughout his service with theCompany in accordance with the SafetyManagement System. MISC are a safetyconscious company who have implemented aSafety Management System on Bunga TerataiSatu in accordance with the ISM Code well inadvance of the mandatory date for doing so.(The full MISC submission is included at page28.)

His first ship with MISC was Bunga Bedaraon a liner service from the Arabian Gulf tothe Far East, from Karachi and Dubai toShanghai via Singapore and Hong Kong. Hejoined Bunga Teratai Satu on 26 June, 2000after a period of leave at his home inKarachi.

On the previous voyage, voyage 406, hecomplained of abdominal pains andexpressed a wish to leave the ship when it

returned to either Port Klang or Singapore.The master on that voyage arranged for themate to see a doctor for his recurrent lowerabdominal pain. The medical examinationrevealed no obvious or immediate problem,but recommended that, if his symptomspersisted, he should return home. The reportstressed that he was currently fit for dutiesat sea.

After arranging for his wife to undertake avoyage on Bunga Teratai Satu he seemedcontent to remain on the ship for voyage407, which would have been completed inlate November. It was his wife’s first voyageon a ship. Arrangements had to be made forhis four children to be cared for by hismother-in-law in Karachi.

The master, who took command inSingapore on 26 October, stated that hedetected nothing in the mate’s ability as awatchkeeper to cause him concern or todoubt his ability to undertake routinewatchkeeping duties, such as alterations ofcourse in open waters.

Soon after the grounding the mate wrote astatement to MISC claiming abdominalpains had forced him to go to the lavatoryafter which he forgot to alter course. Thisaccount was repeated to the accident investi-gators but other inconsistencies in hisinterview, the AB’s account and otherevidence, such as the Telstra telephonerecords, made his evidence implausible.Later he gave a more plausible account tothe Australian Federal Police and theQueensland Parks and Wildlife Service,before appearing in court to answer chargesrelating to breaches of the Great BarrierReef Marine Park Act.

The reason for the timing of the telephonecall at that time of the morning is notabsolutely certain. It was two o’clock in the

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morning in Karachi. The probability is thatsouth of Fitzroy Island the ship would be outof range of mobile phone coverage for sometime. The alternative would have been toplace a call via the maritime systemInmarsat A at $6.30/min.

The groundingBunga Teratai Satu’s GPS was normally onlatitude/longitude display with the voyageplan programmed into the GPS. Cairns pilotground was entered as waypoint 33 (16° 44'S, 145° 45'E) in the GPS. Thearrival alarm sounded at the waypoint andwas cancelled by the master. From the pointat which the pilots disembarked to way point34, in position 16° 52.8'S 146° 02.3'E, therewas about 19 miles to run. Allowing timefor the ship to work up to full speed, theship would have reached the alter-courseposition (Fitzroy Light bearing 218° by3.1miles) at about 0700 (fig. 2).

In case of congestion due to traffic analternative course alteration position hadbeen marked on the chart 1.7 miles beyondwaypoint 34 (about 5 minutes at full speed).This position was not entered in the GPSand would not have triggered any alarm.

After the master left the bridge at 0635, theAB started to clean the bridge. Thisinvolved using a vacuum cleaner at somestage.

From the Telstra records it was establishedthat the mate made an initial call on hismobile phone to the Telstra ‘Phone-away’service at 0644:01. The call lasted for 2 minutes and 25 seconds. He made afurther two calls, one at 0650:02 lasting 19 seconds and a further call at 0651:51lasting 1 minute 17 seconds. The evidencesuggests that it was after this last call that he

phoned his wife from the console on thestarboard side of the wheelhouse, asking herto come to the bridge. The master recalledthat he heard the mate’s cabin door close atabout 0655. The mate’s wife arrived on thebridge some minutes later.

The AB recalled that the mate and his wifewent to the starboard bridge wing sometimebefore 0700, while he was using the vacuumcleaner. They closed the sliding door, heassumed, to stop the noise of the cleanerinterfering with their phone conversation.

The Telstra records show that at 0703:55 acall was placed through the ‘Phone-away’service with a duration of 10 minutes 45 seconds. The call finished at 0714:40.

Just before 0700 the AB finished cleaningthe wheelhouse. At about 0700 he enteredthe GPS position in the GPS Log book as16° 53.0'S 146° 02.4'E. He also completedsome of the other information columns inthe log taken from the GPS screen:

• 1252 miles to go to Sydney;

• current speed 20.1 knots; and

• 62 hours to run.

The plotted position, corrected to WGS9

datum was about 500m south of waypoint34, on the next track to waypoint 35. Theplotted position was consistent with theship’s position as recorded in the Reefcentresystem records of 16° 52.88' S 146° 02.28'Eat a speed of about 21 knots. On this basisthe GPS arrival alarm should have soundedat 0658:17; and the cross track error (XTE)alarm should have sounded at 0701:26.

The AB moved to a position at the front ofthe wheelhouse forward of the steeringposition and waited for the mate to re-enter

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9 Chart datum (GD 66) varies from GPS datum (WGS 84). Off Cairns, GPS plots have to be moved 0.09’ south (167 m) and 0.05 m west (90 m).

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the wheelhouse. Normally, when the ABfixed the ship’s position the mate wouldcheck it. At this time the arrival alarmshould have been sounding and it probablywas. Also, the bottom line of the GPSdisplay would have reverted to the courseand distance to the next waypoint, waypoint35, 164° by 97.2 miles from waypoint 34.The AB could not recall any alarm.

The mate’s amended statement differssignificantly from his original writtenstatement and account of the events leadingto the grounding. He stated that some timeafter 0640 he phoned Karachi to talk to hismother-in-law. He had phoned his wife tocome to the bridge. After a brief conver-sation he handed the phone to his wife. Shewas on the bridge-wing and he stood in thedoorway listening. The bridge-wing doorwas open. At 0700 he asked the AB to plotthe ship’s position and then reverted tolistening to the conversation. He becamedistracted by the phone call and forgot thathe was required to alter course.

At some time after 0715, probably about0718, he went to the chart table. Initially hewas disorientated, assuming the AB hadmarked the 0700 position on the chartwrongly, before he realised that he shouldhave altered course. He ordered the AB toswitch to manual steering and ordered analteration of course to starboard to a courseof 180°(T). Soon after the ship was felt tovibrate and the ship grounded.

At about this time the master arrived on thebridge and stopped the engine.

The mate, apart from being distracted by thephone conversation, apparently relied solelyon the GPS navigator to fix the ship’sposition, ignoring navigation by visual crossbearing or radar. Although the GPS is veryaccurate such reliance does not allow forany cross-check for misread coordinates and

leads to a lack of activity that increases therisk of poor watchkeeping habits. TheCompany’s Bridge Watch KeepingInstructions (Appendix 1 to the BridgeProcedural Manual) require:

12. The watchkeeping officer shallperiodically check the ship’s courseand speed, if conditions permit. Evenif electronic navigation systems areused, the course shall be checked asfar as possible, using the compassand by check bearings and distancesfrom the objects. (Inspector’semphasis)

The Inspector accepts the MISC submissionthat:

The situation that existed following thedeparture from the bridge of the master is thatthe vessel was navigating in good visibility inwaters that were neither confined norcongested where one simple alteration ofcourse was required by the (very experienced)officer of the watch. This alteration of coursehad a margin of safety of more than 7 milesbefore the vessel would run into danger(Sudbury Reef). This with a speed of 20 knots,gave more than 20 minutes for an error to beidentified. (MISC submission, page 30.)

GPS On 21 November, a specialist maintenanceengineer examined the ship’s GPS on behalfof the Inspector. (Figs. 4 and 5 ) No faultwas found either in the aerial or in thereceiver. The ship’s staff stated that the GPSwas functioning properly both before andafter the grounding. It is thereforeconcluded that the GPS was workingproperly and there was no fault in thesystem at the time of the incident.

The Japan Radio Company GPS, aJRL6800, has six operating modes:

• the latitude/longitude mode (L/L) is thenormal operating display;

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Figure 4:Bunga Teratai Satu’s chart table

Figure 5:Bunga Teratai Satu’s GPS

• initialisation mode (INIT) allows entryof gyro and log data;

• waypoint mode (WPT) allows theprogramming of up to 200 waypoints;

• route mode (RTE) is used to select aroute or way point and set alarms;

• satellite mode (SAT) displays thesatellite data;

• special feature mode (SF) is used to setup special operating modes.

The RTE mode allows any of four alarms –‘arrival’; ‘anchor watch’; ‘off course’; and‘boundary’. The arrival alarm may be set ata pre-designated distance from the waypointto alert the navigator. The arrival alarm mustbe cancelled at the GPS receiver. Once thewaypoint has been passed the GPS willautomatically revert to the next waypoint.The GPS will constantly update the courseand distance to the next waypoint. If avessel deviates from the new track by a pre-determined distance the XTE alarm willsound and the letters ‘XTE’ will display atthe lower third, left side of the display. Themaximum value that can be programmed forany of the alarms is 9.9 miles. The alarmswill sound regardless of the position of themode operating switch.

The GPS receiver on Bunga Terati Satu wasprogrammed for the voyage from Singaporeto Sydney. The arrival alarm was set for 0.6 miles and the XTE was set at 0.5 miles.Examination of the GPS on 21 November,and confirmation that the set and its alarmswere operational both before and after thegrounding, would suggest that the set wasfully functional between waypoint 33 andthe grounding position.

With the setting of the arrival alarm at 0.6of a mile and the cross track error at 0.5 of amile, there was a period of about 18 seconds

in which the XTE alarm would have beenoperating at the same time as the arrivalalarm. JRC advised that the two alarmswould sound and each would have to becancelled individually.

It should be pointed out that the GPS alarmis not loud and is identical for all alarmconditions. The alarm cannot be heard onthe bridge wing, or over the noise of thevacuum cleaner when the bridge is beingcleaned. Also it is similar to the DigitalSelective Call alarm, part of the GMDSSsystem, which was located a few metresfrom the GPS.

In submission (page 33) MISC dispute theassertion that the alarm was not loud enoughto attract the mate’s attention.

There is no clear evidence as to when anyaudible alarm was cancelled at, or nearwaypoint 34. The arrival alarm would havesounded just after 0658 and if it had notbeen cancelled, would have continuedsounding until the XTE alarm was finallycancelled after the grounding. The AB couldnot recall either the alarm or the mate beinginside the wheelhouse after the time his wifearrived on the bridge. The mate stated thathe cancelled the alarm, although it is not

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Figure 6:Diagram showing GPS urgent alarm times

Arrival alarm settingOne cable at21 knots,between1 minute 25 secondsafter way point

XTE alarm setting

1 minute 43 secondsafter the way point

Way Point 34

clear if this took place at 0700, or after 0715when he checked the ship’s positionfollowing the phone calls.

DefencesSafe navigation depends upon a number ofshipboard and external defences, whichallow a system to operate safely, reduce thelikelihood of an unsafe act or condition andmitigate the effects of any unsafe act. Thesedefences include the training andcompetency of individuals, shipboardprocedures and the alarm systems on radarand GPS, as outlined above. External to theship, defences include reporting systems,tidal information, sailing directions,lighthouses, buoys and beacons.

Safe navigation depends upon the properwatchkeeping of the bridge team, partic-ularly the professionally qualified officer ofthe watch.

The mate created an unsafe condition byallowing himself to be distracted by thephone call, a very serious professional lapse.The lapse resulted in a situation in which allthe existing on-board defences or barrierswere negated resulting in the grounding. Thepresence of the mate’s wife on the bridgeshould be kept in perspective and should notbe overstated. Her presence of itself did notcause the mate’s inattention, rather it was theuse of the telephone.

In analysing accidents with a view topreventing similar occurrences it is normalto examine what defences failed and why,and what defences were not in place thatmay have prevented the accident. Such anapproach recognises that people do commitunsafe acts for a variety of reasons. Theexamination of defences in no way excusesindividual or collective unsafe acts nor doesit imply any reduced responsibility.

Shipboard defences

Procedures and instructions

Company procedures, instructions andmaster’s standing orders should provide fora framework of safe ship operation. Asnoted earlier, being a container ship BungaTeratai Satu is not required to conform tothe provisions of the International SafetyManagement Code until 2 July 2002. MISC,however, have a number of tankers and otherships that are required to comply and allships in the fleet effectively conform to thecommon safety management regime. BungaTeratai Satu carried comprehensiveoperating procedures issued in January1997, supplemented by the master’s standingorders.

A section of the Company proceduresrelated directly to bridge procedures. Therewas no record of any revision to the BridgeProcedures Manual since its issue in 1997.The document provides for the managementof a navigational watch, leaving andentering port, procedures to be followed inheavy weather, navigation in narrowchannels, navigation in restricted visibilityand navigation in cold areas.

The procedures referenced the secondedition (May 1990) of the InternationalChamber of Shipping Guide, although thethird edition (1998) was carried on board.Bunga Teratai Satu, however had therequired passage plan drawn up. The plandesignated waypoint numbers, waypointpositions, the true course, distance to thenext waypoint and the distance to thedestination, in this case Sydney. Theprocedures made provision for navigation innarrow channels (3 miles or less in width),congested waters and the open sea. Theprocedures do not provide for coastalnavigation. South of Cairns the ship was in‘open waters’.

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The procedures require, amongst otherthings:

The watchkeeping officer shall check course,position and speed every 30 minutes or soonerdepending upon the situation using GPS,NNSS, Log, Radar, Compass and etc. toensure that the ship maintains its plannedroute.

It was accepted by the master that a normalcompetent watchkeeping officer would fixthe ship more frequently than every 30 minutes, in line with the companyprocedures. The frequency of fixing hadbeen every 15 minutes until the master leftthe bridge at 0635.

Procedures are an important part of anyoperational safety system. They are however,also one of the least effective forms ofsafety assurance. Procedural documents donot usually make interesting reading.Individuals may not read them properly orthey may overlook or forget provisions.Intentional non-compliance with procedures(violations) is a major safety problem andmay be involved in up to 70 per cent ofaccidents in some industries.10

The company’s bridge procedures weregenerally adequate. The situation wasroutine and the mate knew what he shoulddo. The ship’s officers accepted thatfrequent fixing was necessary and moreprecise instructions would not have alteredthe outcome.

Bridge resource managementThe International Convention on Standardsof Training, Certification and Watchkeepingfor Seafarers, 1978, as amended in 1995,

specifies as a minimum standard ofcompetence for officers in charge of anavigational watch. Competence to maintaina safe navigational watch includes:

(a) thorough knowledge of effectivebridge teamwork procedures.11

Bridge resource management is a systemwhereby the operation of the bridge team isenhanced as an integrated unit to reduce thepossibility of single person error. Such anarrangement requires a culture where junioror less well qualified members of the bridgeteam can ‘challenge’ a senior person withouta negative ‘response’. The idea of challengeand response is an important defence.

The company procedures made specificreference to the role of the look-out:

The responsibility of the look-out shall be tomaintain an appropriate watch for adequatelyunderstanding the situation in which the shipis placed and hazards during navigation suchas collision and grounding; in addition, thelook-out shall detect ships in distress andwrecks and debris.

Bridge resource management did not existto any effective extent on Bunga TerataiSatu. The mate, though appropriatelyqualified was distracted by the phone calland lacked the proper level of motivation tooperate in a professional manner.

The AB, although aware that the ship hadpassed the alteration point, did not feel thatit was his place to suggest to the mate thathe should alter course. There was also someambiguity as to where the ship was to altercourse off Fitzroy Island. The chart showedtwo positions, waypoint 34 and an alterationpoint 1.7 miles further east on the 118°heading (Figs. 2 and 3). From waypoint 34 a

10 S. Mason, Procedural Violations – Causes, Costs and Cures, in F. Redmill and J. Rajan (Ed) Human Factors in Safety Critical Systems, London: Butterworth Heinemann, (1997).

11 STCW Convention, Table A-II/1, London: International Maritime Organization (1996) pg. 30.

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course line of 164° was drawn and this wasnoted in the voyage plan as the coursealteration point. The second alteration pointrequired an alteration to a heading of 169°and beside the course line on the chart wasnotated:

recommended if any traffic

The second alteration point was not shownon the voyage plan. There was no traffic thatday to impede Bunga Teratai Satu. TheInspector is satisfied that waypoint 34 wasthe intended alteration position and thesecond position was a fall-back position incase of traffic.

The AB was obviously an intelligent youngperson with some six years seagoingexperience. He had learnt to plot GPSpositions but was not familiar with chartsymbols or issues such as scale, ortime/distance estimations. He did not realisethe ship was standing into danger. Heresumed his lookout duties assuming thatthe mate would make the appropriatealteration in due time. The master acceptedthis attitude as quite normal and proper.

This is neither a criticism of the master, whohad no experience of any different system ofbridge organisation, nor of the AB. Such anattitude reflects a large ‘power-distance’index12, a strict hierarchy, between the seniorofficers and junior officers and crew. This isseen as quite normal and proper in someorganisational systems, but such a workingenvironment increases the likelihood of aone-person error.

In submission MISC submitted, amongstother things that:

…the AB can be expected to perform onlythose functions that are within his area ofcompetence and training (as an AB). (MISCsubmission page 33)

The mate’s distraction over a prolongedperiod effectively by-passed the ship-boarddefences, which were more limited than theycould have been.

External defences

Pilotage

Pilotage is compulsory in the area of theinner route between Torres Strait and 16° 40' S (just south of Low Isles andTrinity Entrance).

Although the Great Barrier Reef extends fora further 520 miles, to the south east ofCairns, pilotage is not compulsory in thisarea. A risk assessment relating to oil spillsin Queensland waters notes:

Navigational difficulty for mariners decreasesas the ship moves south down the easternseaboard from Torres Strait. The coastlinesouth of Cairns to Gladstone presents lessdifficulty than to the north of Cairns and thecoastline south of Gladstone once outside theGBR to the New South Wales border isreasonably simple with ample sea room andvessels are far less constrained by draught.13

Navigable water between Cairns and SandyCape is at no point less than 5 miles wide indepths of more than 15m. In all there areabout six course alterations, with none ofthe alterations being greater than 48°.

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12 G. Hofstede, Cultures and Organizations: Intercultural Cooperation and its Importance for Survival, (London: Harper Collins, 1994), p 26.

13 Oil Spill Risk Assessment for the Coastal Waters of Queensland and the Great Barrier Reef Marine Park, (August 2000), Queensland Transport and the Great Barrier Reef Marine Park Authority, pg.31.

A detailed study of pilotage in the innerroute of the Great Barrier Reef is currentlybeing undertaken jointly by AMSA and theQueensland Department of Transport.

Lights and beacons

From Grafton Passage to the south eastextremity of the Great Barrier Reef atHixson Cay, where there is a racon14, there isonly Rib Reef light beacon at the inner endof Palm Passage marking the east side of thepassage of the inner route. Creale Reef lightin Hydrographers Passage is 36 miles off thetrack of the inner route. There should be noneed for marks on the east side of thechannel as there are lights and prominentradar targets with which the ship’s positioncan be fixed. Also, as in the case of BungaTeratai Satu most ships now have thecapability of fixing their position withutmost accuracy by GPS.

However, much of the reef south of GraftonPassage is submerged at all states of tide.There are therefore few features to the eastof the track to give a visual reference of thereef edge.

From the time the master left the bridge at0635, when Green Island was just forwardof the port beam, the ship was travellingtowards a featureless horizon with no visualcues to mark the reef, which was largelysubmerged. Had there been something suchas a beacon to stimulate the mate from hisreverie or alert the lookout then they mayhave reacted to save the situation. As statedabove, if the mate was conducting himselfproperly such a consideration should not benecessary. But he wasn’t.

Reefcentre

The responsibility for safe navigation restswith the ship. Reefcentre operators are not

qualified navigators. Their role is to providerelevant information to the ship-boarddecision maker. The SRS/Reefrepprocedures manual requires operators to usethe radar as well as the TIM to provide shiptraffic information.

Marine Orders Part 56, ‘REEFREP’,provides that a master is obliged to report inthe format provided and states:

…It should be noted, however, that provisionof such information does not in any wayrelieve the crew of the ship, or a pilot, fromtheir normal responsibilities in relation to thenavigation of the ship. In particular, it doesnot relieve the crew of a ship from keeping aproper look-out in accordance with Rule 5 ofthe Collision Regulations.

While the area of radar coverage is limitedand the radars do not perform a precisiontrack monitoring or precision collisionavoidance function, the SRS has to ensurethat, subject to the availability of suitabledata, essential information becomesavailable in time for on-board decisionmaking. Reefcentre has an obligation toprovide the ship with timely essential safetyinformation. Standard operating proceduresissued on 16 April 1999 provide guidancefor the Reefcentre operators. These includethe use of radar to prevent grounding (at 5-3-7, 5-3-8, 5-3-9, 5-3-10, 5-3-17, 5-3-18and 5-3-19):

7. The STS Service is not a navigationassistance service where the servicedirectly assists the on-board naviga-tional decision making and monitorsthe effects of that assistance.

8. Reefcentre VTSOs do not providenavigational assistance or givenavigation direction but they doprovide certain navigationinformation.

24

14 Racon – radar responder beacon.

25

9. The SRS radars, in conjunction withthe TIM (Traffic InformationModule), are required to be carefullymonitored so that developing on-watersituations that might adversely affectparticipating ships can be identifiedwhile there is still time to bring theinformation to the attention of the on-board decision maker for it to be ofuse in a situation where the shipappears to be running into danger.

10. An example of where this might occuris in the case of a clearly definedcourse alteration point on a definiteand well established track, in an areawhere the radar performance is suchthat it is evident that an error in thenavigation of the ship is taking placeresulting in the ship not making theturn at a course alteration point andthus running into danger.

17. Radar provides a significant benefit tothe SRS and gives the ability to betterinteract with participating ships –interaction is a key requirement ofIMO for SRS. The availability ofradar data to generate radar collisionalerts and TIM grounding alerts is animportant safety feature within thesystem.

18. REEFCENTRE is required to providea measured response to a developingsituation detected by radar. Thisrequires careful use of systemgenerated alerts. Alerts must bechecked to establish their cause, and ifthe situation that created the alertcontinues to develop, a warning mustbe communicated to the participatingship or ships involved.

19. In the event that a grounding alert isgenerated by a ship which continuesto remain marginally within a TIM‘restricted area’, the situation isrequired to be closely monitored andif the ship proceeds further into therestricted area a warning is required tobe delivered. In marginal situations itis prudent for REEFCENTRE to delaydelivering the warning while closely

monitoring the situation to see if itdevelops further.

The procedures recognise that an operatormay observe a ship involved in entering anarea of shallow water. In such a case,consistent with the SRS being an informationservice the procedures require (SRS/Reefrep5-4-4):

4. In the event of a developing situationobserved on radar the operators mustcontact the relevant participatingship/s and provide warnings to theseships. Note: It is the responsibility ofthe on-board decision maker(Master/Pilot/navigating officer) tomake decisions regarding thenavigation of the vessel.

Risk of grounding

Risk of grounding warnings are used only inareas of radar coverage. Restricted areas(polygons) have been identified in the TIM inthose areas. These areas enclose shallow waterat the limits of fairways and channels alongTIM legs. An operator alert is activated on theTIM when a ship whose radar track has beentransferred from the RSM15 to the TIM entersone of these Restricted Areas, i.e enters anarea of shallow water (see Section 5-5).

Risk of grounding warnings are delivered onChannel 16 thus:

…Warning. According to my radar you arerunning into danger, shallow water ahead.

Since August 2000, to the date of thegrounding on 2 November, Reefcentre hashad cause to alert ships on four occasionsthat they were standing into danger. Two ofthe ships were navigating Torres Strait; oneship approaching Stagg Patches (close eastof Sudbury Reef); and the other off Mackay.All were unpiloted.

How, then, was the failure of Bunga TerataiSatu to alter course, its subsequent entryinto the restricted area and groundingmissed?

15 RSM – Radar Systems Module.

From evidence obtained through the systemrecords, between 0700 and 0730 three alertmessages were generated. Two of these were‘routine’ at 0701:46 and 0716:0116.

The ‘urgent’ alert message indicating BungaTeratai Satu had crossed into the restrictedzone off Sudbury Reef was timed at0715:50.

Twenty-two seconds before Bunga TerataiSatu entered the restricted zone, theReefcentre Hammond Island radar monitorlost the radar echo of Jin Hui. The operator’sattention was immediately focused onHammond Island radar and the Siriusdisplay of Torres Strait. With subsequentloss from the radar of the real-time echofrom two other ships in the Torres Strait, the

operator remained focused on the HammondIsland display for some ten minutes. Theurgent alert message box on the Siriusdisplay did not register and had goneunnoticed. It was about 15 minutes after thegrounding, after the operator had re-fusedthe targets in Torres Strait and worked VHFtraffic until about 0732, that he realisedsomething was wrong.

However, the system management recordsshow Bunga Teratai Satu had passed itswaypoint marginally before 0700. There wasa period of about 15 minutes, in which theship maintained a steady course for 5 milesdeviating from its planned track beforeentering the restricted area and triggeringthe urgent alert message (fig. 7). Thecircumstances envisaged in 5-3-10 of the

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Figure 7:Bunga Teratai Satu’s track on Sirius

16 The clocks on the three systems (TIM, VHF/Telephone recordings and radar displays) were not synchronised but the three were within two minutes of each other. The time shown accurate to the second is taken from the TIM database

standard operating procedures would appearto apply.

Reefcentre records show that between takingover the watch at about 0655 and 0713 theoperator had been continuously involved inroutine SRS operations (VHF, TIM andradar). The navigation in the area is notcomplicated and a person with the mostrudimentary navigational knowledge couldbe expected to alter course off FitzroyIsland. Without any special stimulus theoperator did not pay any extra attention tothe Green Island radar display.

Unless the operator had specifically lookedat the Green Island radar display during thistime he would not have realised that BungaTeratai Satu had failed to alter course.

The display of an alert message on TIM, ofitself, was such a routine event that it wouldnot necessarily have resulted in the operatoradopting a heightened state of alertness, orgiving it priority over re-establishing theTorres Strait radar/TIM display. In the eventof an alert, the system gives a normalcomputer prompt, a single audible ‘bleep’,that a message has been generated. There isno indication until the message is acceptedon TIM of the level of urgency, or which ofthe 17 alert messages is indicated, or thelocation of the alert.

The workload for operators is not uniformand depends upon the number of ships inthe system. There are times of intenseactivity communicating with multiple shipsentering the system at the same time andfusing targets. At other times activity is lessintense. But there is always a level of VHFtraffic that needs to be monitored and shippositions, requiring updating. Heightenedactivity can also be caused by failures orpartial failures in the system. A furtherworkload is generated by the system alarmsgenerated by TIM and from the radar

display. A number of these are eitherspurious or relatively low priority alarms.

System statistics show that in the calendaryear 2000, there were over 7400 restrictedarea alerts, or just about one each hour ofoperation. There are also separate alarmsgenerated by the four radar displays. Oneoperator estimated that in a twelve hour shiftthere may be over 100 alerts. The mostcommon area for such alerts is the TorresStrait. The overwhelming majority of suchalarms, while not spurious, do not indicate avessel standing into danger. Most alertmessages generated by the system relate tocollisions (usually with buoys) or transiententry into a restricted area.

The sheer volume of alerts desensitises theoperators to the alert messages and alarms.

The restricted area urgent alert message wasdisplayed at 0715:50. Given the containership’s speed of over 20 knots and the levelof attentiveness evident on the bridge ofBunga Teratai Satu, it is doubtful that awarning issued as the vessel crossed into therestricted area would have averted thegrounding. To make initial contact with theship, the Reefcentre operator would havehad to tune the Reefcentre VHF to channel16. The mate on watch would have had toreceive, understand and react to the messagein sufficient time to turn the ship away fromthe danger. The ship under full rudder wouldhave advanced about 4 cables andtransferred laterally some 5 cables. Giventhe two mile restricted area, the mate wouldhave had to have responded and actedpositively within four minutes of crossinginto the restricted zone.

The Queensland Department of Transportsubmitted:

Clearly the prime task of Reefcentre is toreceive reports from participating ships and toprovide information about shipping traffic to

27

* Note - Green Island radar installation is maintained by the Queensland Department of Transport and its avaliabilitydoes not appear in AMSA performance records.

these ships. The prime purpose of the radars isto confirm the position of reporting ships andto identify non-compliant ships. This was thetask on which the operator was engaged inTorres Strait, an identified high-risk area. Itwill be most unfortunate if this reportidentifies him as contributing in any way to amarine incident so clearly caused by adereliction of duty on the part of the ship’swatch keeping officer.

Once again I would urge that the final reportreflect that the Reefcentre had no role in thegrounding of Bunga Teratai Satu.

It was a malign chance that there should bea short period of intense activity inReefcentre just as Bunga Teratai Satu hadentered the restricted area and while itheaded towards the reef.

Reefcentre – Reliability of radarsystemDuring the course of the investigation somesuggestions were made that the radar systemlacked the reliability to track and monitorvessels. The system was not primarilydesigned as a vessel advisory service or toconform with the reliability standards of theInternational Association of Marine Aids toNavigation and Lighthouse Authorities(IALA).

In setting up the radar surveillance system,the project document specified performanceof each of the radars, for which AMSA wasresponsible, on the basis of availability. Thetender document called for 98 per centavailability.

Reefcentre records of radar faults from or atthe four radar sites for the seven monthsfrom 1 June to 31 December 2000 amountto 15 reports of some description or onefault every 12 days. Of these, eight reportsrelated to the Hammond Island radar, four to

Green Island, two to Penrith Island and oneto Warraber Island. The records indicate thatfour of these faults were reported to AMSAin relation to its responsibility under the bi-party Reefcentre agreement.

AMSA’s navigation network performance*

report for the period 1 June to 30 Novembershows, that in the 183 day period, the radarsat:

• Hammond Radar failed twice with atotal down time of two days,

• Warraber Island failed on one occasionfor one day, and

• Penrith Island failed twice for a total ofthree days.

Each of the three radars was available forover 98 per cent of the period withavailability ranging from 98.36 per cent atPenrith Island to 99.45 per cent at WarraberReef.

The AMSA figures relate only to the radarsite equipment and do not account for faultsdown-line of the radar. Other faults haveoccurred from time to time and there weresome differences between the Reefcentrefigures and the AMSA data on these. Suchfaults have included intermittent loss oftargets and tracks, similar to the problemsexperienced by the operator on the morningof 2 November. These faults tend toundermine the operator’s confidence in thesystem and add to the operator workload.

The evidence is that faults either at the fourradar sites or elsewhere within the systemare addressed as a matter of priority.

REEFREP is an effective and innovativeship monitoring system covering some 1200 miles of coastline. The radar element

28

of the system has worked within its designavailability envelope, despite the remotelocations involved and an environmenthostile to electronic systems.

Drugs and alcoholBunga Teratai Satu is a ‘dry’ ship. TheInspector is totally satisfied that neitheralcohol nor drugs, prescribed or illicit, weretaken by any of those involved in thegrounding.

29

30

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ConclusionsThese conclusions identify the differentfactors contributing to the grounding ofBunga Teratai Satu and should not be readas apportioning blame or liability to anyparticular individual or organisation.

1. The significant unsafe act that resultedin the grounding was that the mateallowed himself to become distracted,for a period of about 15 minutes, fromthe navigation of the ship by atelephone conversation between hiswife, who was on the ship’s bridgewing, and his family overseas.

2. From about 0645 to 0715 the mate hadbecome preoccupied with arranging andmaking private telephone calls while theship was in cellular phone range of thecoast, rather than monitoring the ship’scourse, speed, position and his otherwatchkeeping duties.

3. The manner in which the matemaintained his watch on 2 November2000 lacked appropriate motivation andfell well below proper professionalstandards.

Based on the evidence available, thefollowing underlying, or ‘latent’, factors areconsidered to also have contributed or arerelevant to the incident:

4. The ship’s GPS cross-track error alarmwas neither loud enough nor stridentenough to attract urgent attention.

5. The absence of an appropriate level ofBridge Resource Management on thevessel allowed a basic error by oneperson to result in a serious accident.

6. The Reefcentre operator was aware thatBunga Teratai Satu was in the area ofthe Green Island radar coverage, but theloss of radar signal of vessels in TorresStrait caused him to focus solely on theHammond Island display and toconcentrate on re-entering theinformation into the Traffic InformationModule.

7. The frequency of annunciation ofTraffic Information Module alarms andassociated radar alarm systems had ledto the desensitising of Reefcentreoperators to the whole TIM alertingsystem.

8. However, given the setting of therestricted area off Sudbury Reef at twomiles and the speed and circumstancesprevailing on the bridge of BungaTeratai Satu, it is unlikely that anyadvice provided by the Reefcentreoperator under the Reefcentreprocedures would have prevented thegrounding.

In relation to the perception that the radarsystem was not reliable:

9. The radar units operated consistentlywithin the design availability criteria.

31

To the ship operatorsReview the feasibility of introducing BridgeResource Management principles to shipoperations and particularly navigation.

Investigate the advisability of allowingprivate mobile telephone usage on thebridge when the navigation is in the chargeof a single officer.

Review the ship operating procedures with aview to adopting appropriate currentChamber of Shipping Guidelines.

Examine the feasibility andadvantages/disadvantages of fitting audibleGPS alarms in positions other than at theGPS display.

In conjunction with equipment manufac-turers, review volume and characteristics ofcritical GPS alarms.

To ReefcentreReview the ‘alert’ message system, theprioritising of messages and the currentextent of restricted areas south of thecompulsory pilotage zone.

Review the role of Reefcentre and thecurrent ship reporting system to determinethe feasibility of providing a full advisoryservice.

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Recommendations

SubmissionsUnder sub-regulation 16(3) of theNavigation (Marine Casualty) Regulations,if a report, or part of a report, relates to aperson’s affairs to a material extent, theInspector must, if it is reasonable to do so,give that person a copy of the report or therelevant part of the report. Sub-regulation16(4) provides that such a person mayprovide written comments or informationrelating to the report.

The final draft of the report was sent to thefollowing:

Malaysian International ShippingCorporation

The master Bunga Teratai Satu

The mate Bunga Teratai Satu

The Ship Reporting System operator,Reefcentre

Australian Maritime Safety Authority

Department of Transport - Queensland

In response to the submissions the text hasbeen amended where appropriate, otherwisethe parties’ response is as follows:

Malaysian International ShippingCorporation(Additional comments are contained in thetext of the report.)

We note your comments regarding bridgeresource management and have the followingresponse:

On page 6 of the report the Inspectorcomments that the Chief Officer ‘had earlierasked the AB to plot the 0700 position’. Hadthe Chief Officer ordered the AB to plot theposition then there would be an obligation onthe AB to report to the Chief Officer that he

had done so. It is our understanding from thevarious detailed interviews with the ChiefOfficer and AB that the AB took the 0700position and plotted it on the chart entirely onhis own initiative. The AB did this because henoted that the Chief Officer was engaged withhis wife at the bridge wing.

On looking at the chart the AB had noindication (from the chart or otherwise) thatthe vessel had passed an alteration of courseposition; indeed the appearance of the chartindicated that at 0700 the alteration of courseposition had yet to be reached. We haveincluded for your ease of reference a copy ofthe chart illustrating this. The Inspector notesthat the AB (as one would expect of an AB)has no knowledge of scale and distance andtherefore the time it takes the vessel to reachany particular point. As such, he could not ofcourse be expected to have known how long itwould take to reach the apparent alteration ofcourse displayed on the chart. On this basisthe AB had no imperative reason to draw theChief Officer’s attention to the 0700 position.We believe it is unreasonable to criticise theAB for failing to call the Chief Officer on anavigational issue. Bridge team managementdoes not usually require the AB to check thewatch officer’s navigation as, by definition, anAB cannot be expected to have the skills orthe experience required to perform thisfunction.

The criticism of the Master in accepting theabove situation and the description of this asreflecting a ‘large power distance index’ is inour own view quite unfair and fails to takeaccount to the reality on board most ships interms of the working relationship betweendifferent ranks/ratings, bearing in mindrelative abilities, experience, knowledge androles.

The situation was such that the ship was notin confined or congested waters, and thereforeone straightforward alteration of course, witha safety margin of 20 minutes before runninginto a danger, should be no more than couldreasonably be expected of a Chief Officerwith so many years of experience, and aMaster’s foreign-going licence.

We would be grateful if the relevant commentin the report could be removed or otherwisemodified to more accurately reflect the realityof the situation.

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Report Conclusions

A. In the Conclusions, paragraphs 1 and 2refer to the Chief Officer’s navigationwatchkeeping. It is fully accepted that thegrounding occurred due to the Mate’s lack ofattention to the navigation of the vessel for aperiod due to being distracted by thetelephone conversation between his wife andher mother. Although (like the position withmost of the world’s major shipping operators)no written instructions existed on board MISCvessels prior to this incident specificallyconcerning the use of private mobiletelephones on the bridge, neither MISC northe Master were aware, or gave permission forthe Chief Officer to make use of his mobilephone during his bridge watchkeeping. Pleasenote that the Chief Officer was not personallytalking on the mobile telephone (he waslistening to his wife), accordingly, thedistraction was not caused by his own use of amobile telephone.

MISC fully accept point 3 referring to themanner in which the Mate maintained hiswatch which clearly fell well below properprofessional standards (and his own previousstandards – clearly this was a one-off incidentof negligence on his part). However to put thematter in context and give a balance view wefeel that some express recognition should bemade in the report of the fact that the ChiefOfficer was extremely experienced (with over20 years at sea, held a Certificate ofCompetency one grade higher than the rank inwhich he was serving (this certificate wasissued by an authority recognised by IMO asissuing certificates of acceptable standards)and had been sailing on the Bunga TerataiSatu for the previous four months with noadverse comments from his current orprevious Masters on his watchkeepingperformance. Furthermore, MISC hadimplemented all procedures under their(voluntarily implemented) SafetyManagement System to ensure that the ChiefOfficer was suitably qualified andexperienced to serve in the rank of ChiefOfficer before employing him. The ChiefOfficer’s performance was monitoredthroughout his service with the Company inaccordance with the Safety ManagementSystem. MISC are a safety consciouscompany who have implemented a SafetyManagement System on Bunga Teratai Satu in

accordance with the ISM code well in advanceof the mandatory date for doing so (1 July2002).

B. While we note the Inspector’s personalopinion that the GPS cross track error alarmwas not loud or ‘strident’ enough to attracturgent attention, the alarm was (and still is)demonstrably loud enough to be heardthroughout the wheelhouse. The fact that theChief Officer chose to ignore the alarm (andmay have ignored the alarm at whatevervolume it had sounded), this is surely a failurenot of the equipment or the management ofthe vessel but of the Chief Officer himself.

C. Concerning point 5, we do not concede thatthere were or are any lack of bridge resourcemanagement principles on Bunga Teratai Satu.As commented above, the AB has no trainingnor is he required to have any training (underthe STCW Convention or otherwise) in theactual navigation of the vessel. In bridgeresource management theAB/lookout/helmsman can be expected toperform only those functions that are withinhis area of competence and training (as anAB). In this case the AB questioned theadvisability of altering course to starboardwhen he could see a sand cay on the starboardside of the vessel. In our opinion, thisindicates that the AB (within the area of hiscompetence) was in fact acting fully inaccordance with good principles of bridgeresource/team management.

The situation that existed following thedeparture from the bridge of the Master is thatthe vessel was navigating in good visibility inwaters which were neither confined norcongested where one simple alteration ofcourse was required by the (very experienced)officer of the watch. This alteration of coursehad a margin of safety of more than 7 nauticalmiles before the vessel would run into danger(Sudbury Reef). This, with a speed of 20knots, gave more than 20 minutes for anyerror to be identified. The vessel, undernormal operating conditions in open sea mayhave far less time than this in which to reactto a danger yet we would not expect criticismto be levelled at bridge resource managementif an officer of the watch, under such open seaconditions, failed to take action where a safetymargin of a similar order existed.

34

In good bridge resource team management aMaster assesses the navigation tasks aheadand assigns the appropriate resources to thetask. In this case the Master was we believe,quite correct in assigning one suitablyqualified and experienced deck officer to thetask – no more resources were required. Weassume that there is no suggestion that theMaster ought to have remained on the bridgethroughout the voyage to Sydney or that heshould have ‘doubled’ the watchkeepingofficers on the bridge for a straightforwardcoastal passage. We would therefore ask youto seriously reconsider this point.

Queensland Department of Transport

A submission made by the Department isincluded in the text of the report.

35

Bunga Teratai SatuIMO Number 9157662

Flag Malay

Classification Society Lloyd’s Register

Ship Type Container

Builder Daewoo Heavy Industries

Year Built 1997

Owner and manager MISC BHD

Gross Tonnage 21 339

Net Tonnage 8940

Summer deadweight 24 612 tonnes

Summer draught 10.218 m

Length overall 184.00 m

Breadth 27.40 m

Moulded depth 15.80 m

Engine B&W 6S60MC

Power 12 260 kW

Crew 32

36

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w.a

tsb.

gov.

au18

00 6

21 3

72

ISB

N 0 642 20038 6

Bunga Teratai Satu. 05 .2001