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Grounding of the Australian flag training vessel Wyuna
Tamar River, Tasmania | 19 October 2000
ATSB Transport Safety ReportMrine Occurrence Investigation161Final
Investigation
Grounding of the Australian flag training vessel Wyuna
Investigation
Tamar River, Tasmania | 19 October 2000
ATSB Transport Safety ReportMarine Occurrence Investigation161Final
Report No 161
Navigation Act 1912Navigation (Marine Casualty) Regulations
investigation intothe grounding of the Australian flag training vessel
Wyuna in the Tamar River, Tasmania
on 19 October 2000
Issued by the
Australian Transport Safety Bureau
March 2002
ISBN 0 642 20043 2
Investigations into marine casualties occurring within the Commonwealth's jurisdiction areconducted under the provisions of the Navigation (Marine Casualty) Regulations, made pursuant tosubsections 425 (1) (ea) and 425 (1AAA) of the Navigation Act 1912. The Regulations providediscretionary powers to the Inspector to investigate incidents as defined by the Regulations. Wherean investigation is undertaken, the Inspector must submit a report to the Executive Director of theAustralian Transport Safety Bureau (ATSB).
It is ATSB policy to publish such reports in full as an educational tool to increase awareness of thecauses of marine incidents so as to improve safety at sea and enhance the protection of the marineenviroment.
To increase the value of the safety material presented in this report, readers are encouraged to copyor reprint the material, in part or in whole, for further distribution, but should acknowledge thesource. Additional copies of the report can be obtained from:
Inspector of Marine AccidentsAustralian Transport Safety BureauPO Box 967Civic Square 2608 ACT
Phone: 02 6274 64781800 621 372
Fax: 02 6274 6699Email: [email protected] address: www.atsb.gov.au
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CONTENTS
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
Sources of information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Acknowledgment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Narrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
Wyuna . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
The Australian Maritime College . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
Management of the vessel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
Tamar River pilotage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
Preparation for the exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
The incident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
Comment and analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
Master’s report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
Manning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14
Bridge Resource Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14
Conduct of the passage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
Echo sounder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16
SOPEP and tank soundings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17
Anchors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17
Fatigue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17
Ship management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25
Submissions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27
Wyuna . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28
Figures
1. Wyuna . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .iv
2. Plan of Wyuna . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
3. Chartlet of Tamar River . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
4. Chartlet of area including tracks from ECS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
5. Grounding: Wyuna, Events and causal factors chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20
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FIGURE 1:Wyuna
SummaryOn 19 October 2000, the Australian MaritimeCollege vessel Wyuna was being used to trainstudents in night pilotage exercises in theTamar River.
The exercises had commenced before dawnthat morning, resuming at 2000 under themaster’s supervision. An outward passage andan inward passage were satisfactorilycompleted and a second outward passage wasstarted.
The tide was ebbing. The sky was overcastwith moderate rain, the wind was SSE at force4/5 and the visibility was moderate to good.During the early stages of the passage out, themaster observed that the vessel wasovershooting course alteration points. On bothoccasions he verified Wyuna’s position andbrought the vessel back on track.
After clearing North West Bank beacon, themaster became disorientated and confusedNorth West Bank Beacon for Shear RockBeacon. He instructed the student on the con
to set a course to take Wyuna clear of theriver, but the vessel was set on course forShear Rock. At 2305, Wyuna struck ShearRock.
The master stopped the engines and checkedthe electronic chart display, which showed thevessel on Shear Rock. The tide was setting theship across the rock but, about 2 minutes later,the ship was afloat once more, being carriednorthward across the channel.
The master let go the port anchor with ashackle1 and a half of chain, but this did notarrest the ship’s drift and, at 2315, the shipgrounded once more, on Middle Bank. Thechief engineer reported that there was noapparent damage to machinery, so the masterused the engines to prevent the ship fromgoing further aground and, at 2317, Wyunasteamed back into the channel.
The master took the ship back to anchor atBell Bay while continuing to check the vesselfor any damage. No oil or water was lost fromthe ship but numbers 10 and 11 double bottomtanks were making water through sprungseams and rivets.
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1 A shackle is about 27 metres
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Sources ofinformationMaster and crew of Wyuna
The Australian Maritime College
The Port of Launceston Authority
Australian Maritime Safety Authority
AcknowledgmentThe Australian Transport Safety Bureau isgrateful for the assistance provided by thestaff at the Australian Maritime College’s shipsimulator unit in simulating the incident.
The Inspector is grateful to Interdynamics PtyLtd ( www.interdynamics.com) for thecomputer program, FAID 330E, which wasused in the analysis of the fatigue factors.
Certain reproductions of chart sections in thispublication are reproduced by permission of TheAustralian Hydrographic Service.
© Commonwealth of Australia 1997. All rightsreserved.
Other than for the purposes of copying thispublication for public use, the chart information fromthe chart sections may not be extracted, translated, orreduced to any electronic medium or machinereadable form for incorporation into a derivedproduct, in whole or part, without the prior writtenconsent of the Australian Hydrographic Service.
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FIGURE 2:Plan of Wyuna
1011
F W
Bal
last
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Narrative
WyunaWyuna is an Australian flag training vesselowned and operated by the AustralianMaritime College (AMC) based inLaunceston, Tasmania. The vessel’s primaryfunction is to provide practical seagoingexperience to the nautical and engineeringstudents attending the college.
Wyuna was built in Glasgow, Scotland, in1952 as a pilot vessel for the Port Phillip SeaPilots, to operate off Port Phillip Heads. Thevessel was built under Lloyd’s survey andmaintained to Lloyd's class until 1981, when itwas presented to the newly-created AustralianMaritime College. Since then, all surveys ofthe vessel have been conducted by theAustralian Maritime Safety Authority.
Wyuna is 63.5 m in length overall and has abeam of 11.9 m. It has a displacement of 1 831 tonnes at its maximum draught of 5.0 m.
The accommodation is situated above theengine room and tank spaces. There are twowheelhouses located at the forward end of theaccommodation. The upper or control bridgeis located on the control bridge deck and thelower or training bridge is located on the boatdeck. The vessel has 45 berths for its crew andstudents, located on 3 decks, behind thetraining bridge, on the boat deck, the upperdeck and the main deck. The galley and messare located aft on the upper deck below a fullyequipped radio room.
Wyuna’s propulsive power is provided by two515 kW electric motors driving twin fixed-pitch propellers. Power for the electric motorsis provided by three English Electric, 380 kW,
400 V direct current generators each driven bya 476 kW, 4-stroke, diesel prime mover.Electrical power for ship's services is providedby two 150 kW, three 60 kW and one 50 kW,220 V direct current generators. The vessel’smaximum service speed is 13 knots when allthree main diesel generators are supplying theelectric propulsion motors.
Below most of the engine room space aredouble-bottom water ballast tanks.Immediately forward of the engine room aredeep tanks, which are used for distillatebunkers and forward of these tanks is morewater ballast space in a combination of doublebottom and deep tanks.
Wyuna is equipped with an extensive array ofnavigation aids including a sophisticated PC-based electronic chart system (ECS)integrated with a differential globalpositioning system (DGPS) and 3 radars, onewith ARPA. The vessel also has a recordingecho sounder, a course recorder, gyro andmagnetic compasses and equipment fortraining students in radio communications.
Wyuna’s regular complement consists of themaster, mate and 2nd mate, chief engineer 1st
and 2nd engineers and the bosun, allpermanent employees of the AMC. When anovernight trip is planned with students, a cookis engaged. Students then form the rest of thecrew, performing the duties of deck andengine room ratings.
The mates and engineers work 4 on, 8 offwatches when the vessel is at sea. The regularofficers instruct students during their periodson and off watch and these instructions maybe supplemented by lectures from otherlecturers who may be on board.
Wyuna’s master had been the vessel’spermanent master since 1992. He also had 10years command experience in the Australian
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Merchant Navy and had held an AustralianMaster Class 1 Certificate of Competencysince 1974. In addition to regular duties asmaster of Wyuna, he is the coordinator for theAMC’s gas tanker courses. At the time of theincident, the master held a current pilotageexemption certificate for the Tamar Riverissued by Marine and Safety Tasmania forvessels under 65 m in length.
The mate on board Wyuna at the time of theincident had a Chief Mate Class I certificateand also held a pilotage exemption for theTamar River.
The 2nd mate also had a Chief Mate Class Icertificate, but he did not have pilotageexemption for the Tamar.
The Australian Maritime College The Australian Maritime College wasestablished by an Act of Federal Parliament in1978 to service the needs of the Australianmaritime industry. In 1980, the AMC acceptedits first intake of shipping officer cadetstudents and has, since then, providedprogressively diverse services to the maritimeindustry. This includes teaching in areas ofmaritime operations, ocean engineering,marine engineering, naval architecture,fisheries and maritime business. In addition toteaching, the AMC performs research andindustry consultation activities in many of itsareas of maritime expertise.
The AMC has infrastructure located on twomajor campuses in Northern Tasmania. Themain campus is located at Newnham, a suburbof Launceston, and this is where the faculty ofMaritime Transport and Engineering is based.The faculty of Fisheries and MarineEnvironment is located at Beauty Point, about50 km north of Launceston, on the west shoreof the Tamar estuary.
The faculty of Maritime Transport andEngineering provides a range of courses fordeck and engineer officers which are STCW ’95 compliant and approved by theAustralian Maritime Safety Authority(AMSA). One of the faculty’s resources is thetraining vessel Wyuna, which is used toprovide (among other things) practicalnavigation, pilotage, ship handling andsurvival training for advanced diploma anddiploma level nautical science students.
Management of the vesselEach of the major physical facilities of theAMC has a manager. In the case of Wyuna,the master is the manager, responsible for itsoperation in compliance with the NavigationAct and associated Regulations and MarineOrders. He is also responsible for the trainingof students undertaking courses on board andfor conducting safety courses.
Tamar River pilotage The Tamar River is located in northernTasmania and flows northward fromLaunceston to its mouth at Low Head.Pilotage is compulsory in the Tamar River forall vessels 35 m or more in length. Thepilotage, from the boarding ground off LowHead to Bell Bay (Port Dalrymple), is about11 miles in length. See chartlet (on page 7)for further detail. The channel is about 280 mwide at the entrance and has a least width ofabout 210 m.
The pilotage plan used by Wyuna consisted of9 legs between the vessel’s berth and aposition clear of Middle Reef.
The Port of Launceston Authority confirmedthat on the night of 19 October all lightbeacons in the outer reaches of the TamarRiver were operating.
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FIGURE 3:Chartlet of Tamar River
Warning Not to be used for Navigation
ACT
NSW
NT
Qld
WA
SA
Vic
Tas
NT
NSW
ACT
Location ofincident
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Preparation for the exerciseTwenty five nautical students were due toundertake navigation and pilotage training inmid October 2000. Notes for the conduct ofthe exercise were provided to the students aweek in advance to give them time to
familiarise themselves with the passage planand instructions before joining the vessel. Thenotes, entitled Bridge Resources Management,contained instructions for both visual andblind (zero visibility) pilotage.
FIGURE 4:Chartlet of area including tracks from ECS
Intended track
Actual track
315º
2305
2315
Warning Not to be used for Navigation
Fl.G. 2s 6m 6MYellow Rock
The notes stated:
Outline
The exercise will be conducted in the trainingbridge of Wyuna. Control of the vessel will beby students operating in the training bridge witha lecturer present. A senior officer…will be inthe control bridge where direct steering andengine control can be taken in the event it isdeemed necessary. …
…Navigation will be by use of Bridgemasterradar, differential GPS and electronic chart. Astandard paper chart is used as the basis fornavigation, but conventional position fixingtechniques will not be used. Instead, radarparallel indexing and direct assessment of crosstrack error from pre-designated tracks on theelectronic systems is to be the means of guidingthe ship through the passage. Rate of turn, waterreferenced speed and underkeel depth are allindicated close by the other equipment in thewheelhouse front.
At the AMC jetty, the ship will be handed overto the students after unberthing, clear of theberth and headed North. From this position, theship will complete the complete river pilotageuntil reaching a point on the entrance leadsmarked as waypoint 10. Here the ship will beturned about and the pilotage re-run back to theAMC jetty.
For zero visibility, all the bridge windows willbe blanked….
… Students will operate the vessel in teams of3, …master, duty officer and helmsman. At pre-determined points, rotation between duties willtake place.
Operational notes
…This is a very difficult exercise becauseeverything happens so quickly and you mustorientate yourself entirely on the instruments.You will have the pilotage courses plotted on apaper chart on a desk in the forepart of thewheelhouse, duplicated on an electronic chartdisplay next to this, and again as a radar map onthe Bridgemaster radar next to this. You will nothave the time to fix the ship’s position on thepaper chart. Consequently, you must navigate bysight, radar and electronic chart. …Below arelisted some of the commonly experiencedproblems….
Altering course too late and too little, resultingin heavy overshoot on the turns.
…Making course adjustments too late. You haveno time to spare and very little margin for error
…Over correcting...
…You can not afford to ignore your radar. Onlythe radar can inform you of any traffic in thevicinity. In addition, the value of both theelectronic chart and the radar map dependsentirely on the accuracy of the DGPS receiver. Ifthe DGPS receiver drops out of DGPS mode,the radar map and the electronic chart areuseless. …you should always have a parallelindex line set for the next clearing point. Such asetting can be made by the officer of the watchas you are going, and clearing distances frommain points are given in the pilotage notesbelow. …Index lines must be set allowing forthe current gyro error.
The incidentOn 16 October 2000, 25 Master Class 1students joined the training vessel Wyuna atBeauty Point to spend five days conductingnavigation and pilotage training aroundnorthern Tasmania. The training included dayand night pilotage exercises in the TamarRiver. The students were divided into 7operational groups of 3 and one group of 4with each group assigned a letter from ‘A’ to‘H’.
The vessel, with a draft of 3.8 m forward and4.25 m aft, was operated around the clock.The students were rotated through the variousactivities including practical exercises andlectures by the Wyuna’s master and officers.At the end of the first day, each group hadcompleted a transit of the Tamar River, eitherinward or outward, during daylight. Duringthese pilotage training runs, each student hadperformed the role of (a) master with the con,or (b) officer of the watch assisting themaster, or (c) helmsman, each operation beingsupervised by Wyuna’s master or mate duringtheir respective watches. The pilotage training
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utilised a passage plan with all waypointsprogrammed into the ECS on the trainingbridge.
The vessel then made a short voyage toconduct navigation exercises off FlindersIsland. Wyuna returned to the anchorage offthe Tamar River late on 18 October, weighinganchor a little before 0400 on 19 October tostart night pilotage exercises.
The purpose of the night pilotage exercise wasto familiarise students with piloting the vesselvisually, using illuminated channel buoys,beacons and leading lights. During theexercise, the master or first mate monitoredthe vessel’s progress using the integratedECS/DGPS, providing real time positioninformation. As the ECS monitor was locatedon the forward console in the training bridge,the master dimmed the screen during theexercise to ensure that the students only usedvisual cues and radar for navigation of thevessel. The students were advised to monitorcross track error using parallel indexing onthe ARPA equipped radar.
Night pilotage exercises started at 0400 on 19 October under the supervision of the firstmate. Two runs were completed before dawnwith student groups A and B. Later in themorning, after completing the exercise themate informed the master that the vessel wasset down heavily onto Barrel Spit beacon bythe flood tide during the second pilotage run.He also advised the master that he found itwas difficult to get a good visual perspectiveat night and thus difficult to judge distance.
After a day’s training in ship handling, nightpilotage resumed at 2000 under the master’ssupervision. The tide was ebbing. The sky wasovercast with moderate rain and the wind wasfrom the south-south-east estimated at force 4-5 (about 16-17 knots). Visibility wasmoderate to good.
Student group C operated the vessel outward,the ship being turned in clear water and groupD made the return run upriver, the ship beingturned off Orari Bank beacon. Visibilityremained moderate to good but, with the rain,visibility from the training bridge wassomewhat reduced as the windscreen wiperswere out of order.
At about 2230, student group E, comprisingthree students, commenced the next outwardrun. Each student was again allocated a role,with one on the helm, another acting as pilotwith the con and the third acting as officer ofthe watch keeping a lookout and monitoringthe radar. During the early stage of this runthe master twice observed the vessel hadovershot the course alteration points in the 2 knot ebb tide. On both occasions he verifiedWyuna’s position by turning up the brillianceon the ECS, taking control to bring the vesselback on track.
North of Garden Island, at about 2245, thestudent who had the con took over ashelmsman, one of the other students took thecon and the third student was the officer ofthe watch.
The student who had the con (the student‘master’) felt that, just after he had altered thecourse to 005° off Bombay Rock, the masterhad taken control of the vessel. His recall ofevents was that the master had taken controlafter that alteration and that the master madethe next alteration of course to 345° as well asthe alteration to 315° off North West Bankbeacon at about 2259. He also recalled thatthe master then handed the con back to him asthe vessel was coming around to 315°. Hechecked the course on the chart and, realisingthat it should have been 327°, he ordered thehelmsman to steer 320°, then 325°.
As the ship’s head altered to starboard, themaster was stated to have advised the student‘master’ to keep the ship headed between the
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two beacons that could be seen ahead. Thestudent ‘master’ adjusted the course to 320°,but the master said that a course had to be setto steer between the lights. At that point, thisstudent ‘master’ ordered a course of 315° tobe steered, after which the master was statedto have expressed his satisfaction, advisinghim to steady the ship on that course and thatthey must not let the ship be set to starboardonto Barrel Spit.
The master remained confident that the shipwas safe, not feeling the need to verify theship’s position using the electronic chart.None of the students saw Shear Rock beaconeither visually or on the radar and theydeferred to the master's instructions, thestudent ‘master’ feeling that the master hadtaken over.
At 2305, Wyuna struck the bottom with aprolonged scraping and shuddering. Themaster stopped the main engines immediatelyand turned up the brilliance of the ECS. Theelectronic chart showed Shear Rock beaconwas bearing 086° at 150 m. After the initialimpact, the vessel continued to touch thebottom as it was pushed across Shear Rock bythe tide. About 2 minutes later, Wyuna floatedclear with the tide carrying the vessel rapidlynorthward across the channel.
The master had contacted the chief engineerby this time to advise him of the situation andthe latter started checking the machineryspace for signs of damage. The master wasconcerned that the vessel would ground againon the other side of the channel, on MiddleBank. However, he was unwilling to use themain engines until the chief engineer reportedthat it was safe to do so and ordered thestudents on the bridge to the forecastle to letgo the port anchor.
By about 2310, the port anchor had been letgo with 11⁄2 shackles of chain. However, the
anchor failed to hold and could be clearlyheard dragging over the seabed. At about thistime, the master instructed the vessel’s crew tosound around and assess the damage.
At 2315, Wyuna grounded a second time, thistime on the southern end of Middle Bank. Thechief engineer reported that the engine roomwas making no water, and that there was noapparent damage to the propulsion machinery.The master felt that the tide was carrying thevessel further aground so rang half ahead onboth main engines at 2317, steering clear ofMiddle Bank, back into the channel.
Once Wyuna was back in the channel, themaster verified that the steering wasoperational, that the main engines wererunning without a problem and both the logand echo sounder were still working. He thenreturned to the anchorage at Bell Bay, workingup speed slowly to check for normal response.In the meantime, the vessel's crew weremaking a more detailed examination of allwater ballast, fresh water and fuel oil tanks.
Wyuna dropped anchor northwest of Bell Baybeacon at 0005 on 20 October. By this time itwas confirmed that nos. 10 and 11 starboarddouble bottom water ballast tanks in theengine room were pressurised, indicating thatthey were open to the sea, but all other spacesappeared intact. These tanks were pumpeddown and the rate of water ingress was notedas slow, indicating leakage from sprung seamsand rivets. Soundings were checked oncemore and the water around the vessel carefullystudied for any signs of oil leakage.
Early in the morning of 20 October, Wyunawas moved from the anchorage to be berthedat the AMC jetty at Beauty Point at 1038. Themaster subsequently notified the Port ofLaunceston Authority and the AustralianMaritime Safety Authority of the incident.
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Comment andanalysis
EvidenceOn 24 October, two investigators from theAustralian Transport Safety Bureau (ATSB)attended Wyuna at Beauty Point. The masterof the vessel was interviewed and provided acomprehensive statement of events. The threestudents on the bridge at the time of theincident and the Director of the Faculty ofEngineering and Maritime Transport were alsointerviewed.
Other evidence, including copies of the ship’sdocumentation, logs, and the passage plan wasobtained. Hard copies of the Wyuna’s ECSreal-time passage were provided to the investi-gation. This record showed a limited numberof time positions. The vessel’s course recorderwas not operating at the time of the incidentand the bridge team did not maintain a bridgemovement/bell book. Approximate times ofpassing beacons have been calculated basedon a speed of 8.5 knots (262 m/min).
A simulation of the incident using the ECSreal-time passage information was conductedfor the investigators in the AMC’s shipsimulator facility. The Tamar River pilotage isa standard simulation used in the collegesimulator and two runs of the pilotage wereconducted. Both simulations were conductedusing conditions of visibility as close aspossible to those experienced on the night ofthe incident. The first simulation usedWyuna’s actual track from the position of thelast alteration prior to the grounding, to theposition of the first grounding on Shear Rock.The second run was conducted using Wyuna’sstandard passage plan which, starting from the
same position as the previous simulation, ranto a point in the channel adjacent to MiddleBank.
The simulations showed that Shear Rockbeacon should have been visible from thebridge that night and also clearly showed therelative positions of the shore lights at thetime of the grounding.
Master’s reportThe master’s report on the grounding stated inpart:
At the time of the incident, Wyuna wasconducting night pilotage training exercises withMaster Class 1 students …on their fourth day oftraining on board…
The primary purpose of the exercise is tofamiliarise the student with the task oforientating the vessel visually by use of thelighted channel buoys, beacons and leadinglights. Position monitoring and vessel tracking isperformed by a Differential GPS system loadingthe position once per second onto anECDIS/RCDS. The DGPS is configured toapply fairly stringent masks to the satellitesignals, ensuring high quality fixes or nothing.The system cannot default to GPS or DR andalarms on losing lock for any reason. Thisensures positional fixing of 5 metres or better orno positions at all. For the purposes of nightpilotage training, this system is running, but thedisplay turned off by darkening the screen.
…a Bridgemaster radar is in operation forstudent and supervisor use. Students areencouraged to monitor vessel XTE (cross trackerror) by using parallel indexing, but not all areable to do this in the river.
Night pilotage runs commenced at 0400 on the19th, under the supervision of the Chief Officer.2 runs only were made as by then it was dawn.The Chief Officer reported being set downheavily onto Barrel Spit Beacon by flood tide…. This was our first night time operation in theriver this year and we were ourselves out offamiliarity with it.
…night pilotage resumed under my supervisionat 2000. The sky was overcast with moderate
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rain…. Visibility remained moderate to good,but we experienced some loss of clarity ofvision from rain on the wheelhouse windows.The windscreen wipers on Wyuna do not workproperly.
His report went on to state:
The students did not see Shear Rock light anddeferred to my instructions, presumably out ofrespect for my years experience with the shipand this pilotage.
Manning Wyuna was manned by an appropriatelyqualified master and appropriately qualifiedmates and engineers. At the time of thegrounding, the bridge team consisted ofWyuna’s master and three students.
The students held certificates of competencyand formed the deck crew complement,concerned with navigation safety. They wereMaster Class 1 candidates with varyingseagoing backgrounds.
For the purposes of training in pilotagetechniques and operating the ship when underway in pilotage waters, a person holdingpilotage qualifications was required to be incharge of the ship. Both the master and mateheld the appropriate pilotage exemptionqualifications.
The master had frequently entered and exitedthe port as part of the training regime for thevessel. However, both he and the mate hadonly made one night passage in the last year,about a year previously, and only 2 or 3 nightpassages in the last 8 years. They both hadlimited experience in night pilotage in theriver.
The notes provided to the students before theexercise started stated that during the exercise:
A senior officer…will be in the control bridgewhere direct steering and engine control can betaken in the event it is deemed necessary.
No such officer occupied the control bridge.The master was fulfilling the dual role of
instructor and pilot in the compulsory pilotagearea.
The role and responsibility of the trainees asboth crew and students was ambiguous. Thestudents were qualified mariners and they hadsea-going experience that should have beenuseful in ensuring a safe passage.
Bridge Resource ManagementThe AMSA Marine Notice, no. 7 of 1994, onBridge Resource Management (BRM) andNavigational Practice reminds seafarers,shipowners and pilots of the importance ofsound BRM and watchkeeping techniques toenhance safety and reduce human andsystemic errors while navigating ships. Thenotice points out that BRM should include aclear identification of the bridge teammembers at all stages of a voyage, their dutiesand responsibilities and the line of commandincluding the levels of authority in making,challenging or responding to decisions andinstructions.
The notice included a list of errors that hadresulted in casualties, such as insufficientsupport to the master, inadequate monitoringand a failure to detect and challenge adeviation from the passage plan or standardoperating procedures.
The master’s procedure for taking control ofthe vessel from a student was that the masterwould advise the student that he had the shipand was taking control. He emphasised thatmembers of the bridge team should questionany departure from the set plan. While he hadbriefed the students verbally on procedures fortransferring the conduct of the vessel, no suchprocedures were contained in the notesdistributed to the students.
There was confusion over who had control ofthe vessel. Off North West Beacon, thestudent ‘master’ ordered the correct alterationof course to clear Shear Rock beacon. Themaster, however, countermanded the alteration
to starboard, expressing satisfaction with acourse of 315°. The master considered that hehad taken control only for the purposes ofgetting the vessel back on track afterovershooting course alteration points.However, the student ‘master’ thought that themaster had taken the con and had retainedcontrol until the vessel was off North WestBank. The student ‘master’ did not questionthe master.
The student OOW offered no advice as part ofthe bridge team. He had not orientated himselfin the ten to fifteen minutes since he assumedthe role of OOW. The notes for the riverpassage given to the students had instructed:
A standard paper chart is used as the basis fornavigation, but conventional position fixingtechniques will not be used. Instead, radarparallel indexing and direct assessment of crosstrack error from pre-designated tracks on theelectronic systems is to be the means of guidingthe ship through the passage
The student OOW had not mastered thesetechniques. It was the middle of the night andhe was not familiar with the ship or the river.He had been monitoring the radar but he wasnot familiar with the set. He saw all thebeacons on radar with the exception of ShearRock beacon, which he thought might havebeen lost in clutter or was not visible becauseit was too close to the ship.
He did not know the ship’s position, or whichbeacons Wyuna had passed or which beaconthey were due to pass. Times of passingbeacons were not marked on the chart and inthe absence of a bridge movement book, therewas no ready reference for the student ‘OOW’to establish the next beacon to be passed.
The student ‘helmsman’ had been concen-trating on maintaining a course when thevessel grounded. With the tide astern, he hadfound it difficult to steer the courses given tohim and was not able to observe or follow thevessel’s progress northward in the river.
All the students, however, had been briefed onthe exercise and they had completed daylighttransits. For the student ‘OOW’, one of hisduties was to monitor the vessel’s progress,informing the student ‘master’ of anyproblems. The student ‘OOW’ had not set upparallel indexing lines on the radar and, justbefore the ship grounded, he was looking outto port where he was apparently able to seeShear Reef, thinking that it was ‘a bit close’.
At no stage, during the critical period of thevoyage, was the course deviation to the westof Shear Rock beacon, an east cardinal mark,questioned.
There was a lack of oversight of the safenavigation of Wyuna through the absence of asuitably qualified person on the controlbridge. When Wyuna’s master ordered anincorrect heading he was not questioned bythe student ‘master’, nor did the student‘OOW’ take an active part as a member of thebridge team.
Conduct of the passage The three students forming group E startedtheir exercise at about 2230, taking the rolesof pilot, OOW and helmsman.
At about 2245, north of Garden Island, thestudents changed roles, with the nextalteration off Bombay Rock due in about threeminutes. The student previously acting asOOW took the con as pilot, while the othertwo interchanged. The tide was ebbing, givingWyuna a speed over the ground of about 8.5 knots.
Off Bombay Rock, Wyuna overshot thealteration of course position and the masterintervened and ordered the course to steer tothe next alteration point. The master hadapparently, though not explicitly, taken controland ordered the alterations at the next twocourse alteration points at Toroa Patch and offNorth West Bank beacon.
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The next two beacons to seaward of NorthWest Bank beacon were Barrel Spit (flashingred every 2 seconds) to be left to starboardand Shear Rock (flashing 3 every 5 seconds)to be left to port. These beacons were about700 m and 1200 m, respectively, ahead of theship at this time
The student ‘master’ understood that themaster had handed him the con and heordered a course to take Wyuna to the east ofShear Rock. But the master intervened again,ordering a course of 315°. The master waspreoccupied with clearing Barrel Spit as,earlier in the day, the mate had told the masterthat the flood tide had been setting the vesselonto Barrel Spit.
However, on a heading of 315°, the vessel wasnow heading between Yellow Rock beacon(flashing green every 2 seconds) about 2300 mfine to port and Middle Bank beacon (flashred every 2 seconds) about 2000 m fine tostarboard. Shear Rock beacon was now tostarboard, instead of to port. The master’scourse of 315° was taking Wyuna onto ShearRock.
The navigation beacon lights should havebeen clearly visible, despite the rain. Therewere no background lights to obscure ShearRock light beacon as, from Wyuna, the beaconwould have been well clear of Low Head andother land-based lights. Neither the master,nor the students noticed that a light thatshould have been left to port on the outwardpilotage was, in fact, to starboard. It seemsthat no one on the bridge of Wyuna saw ShearRock light.
For some reason, the master had becomedisorientated and had ordered a headingcorresponding with the next leg of thepassage, from Barrel Spit to the sea. It was asthough he thought that the vessel was furthernorth and that he was altering course off
Shear Rock beacon. A contributory factor mayhave been that the lights on Barrel Spit andMiddle Bank beacons have identical charac-teristics. However, there was an inconsistencyin that the master had cautioned the studentsnot to allow the vessel to be set on to BarrelSpit. Such a warning was not consistent withbeing north of the Barrel Spit light beacon onan ebb tide.
On earlier occasions, the master had used theECS display to check when Wyuna hadovershot course alteration points. On thisoccasion, had he done so, the danger ofgrounding would have been immediatelyapparent.
Echo sounderThe echo sounder could have provided visualand audible indication that Wyuna wasstanding into danger and it was operatingthroughout the exercise. The channel betweenPoint Effingham and Yellow Rock is deepwith steeply shelving boundaries. Anyexcursion outside the channel would havebeen immediately obvious on the echosounder.
The master was in the habit of using the echosounder at all times. However, in the minutesbefore the grounding he was confident thatthe ship was correctly positioned in thechannel and did not look at the depth belowthe keel.
The echo sounder unit included an adjustablesetting at which an audible alarm wouldsound. Had the alarm been set to sound if thevessel left the general depth of the channel, orset at a lesser depth of, say 10 m, it wouldhave provided aural indication that Wyuna hadleft the channel.
At a speed of 8.5 knots, there would havebeen about 60 seconds for corrective action tobe taken.
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SOPEP and tank soundingsThe shipboard oil pollution emergency plan,SOPEP, for the vessel requires that a report bemade when the vessel has grounded. Thoughthe master stated that he considered itunnecessary at that time, the plan does notpermit a delay in submitting this report.
The state of the vessel’s tanks had not beenrecorded regularly. In the event of a groundingor a collision, comparison of soundings givesan indication of where the ship’s hull has beenbreached. Knowledge of the state of the tanksis important for identifying potential sourcesof pollution and for calculating damagestability.
AnchorsIn the event of an engine breakdown, anchorscan be used to stop a vessel and prevent agrounding.
However, aboard Wyuna, anchoring in anemergency was not included in the inductionprocedures. A ship would only use its anchorsin the channel between Yellow Rock and PointEffingham in the most dire emergency, giventhe width of the channel and the rate of tidalflow.
The use of the anchor after the initialgrounding to arrest the ship’s drift, preventingfurther grounding, was sound, but the lengthof chain paid out (about 11⁄2 shackles) wasinadequate in that depth of water (30–40 m)and strength of tide.
The International Association ofClassification Societies Requirementsconcerning Mooring and Anchoring (IACSReq. 1994/Corr.95) makes the followingstatements regarding the design of anchoringequipment:
A1.1.2
The equipment is therefore not designed to holda ship off fully exposed coasts in rough weather
or to stop a ship which is moving or drifting. Inthis condition the loads on the anchoringequipment increase to such a degree that itscomponents may be damaged or lost owing tothe high energy forces generated particularly inlarge ships.
A1.1.4
The equipment number formula for anchoringequipment here under is based on the assumedcurrent speed of 2.5 m/sec, wind speed of25 m/sec and a scope of cable between 6 and 10,the scope being the ratio between the length ofchain paid out and the water depth.
FatigueIn terms of vessel operations in pilotagewaters, the manning levels on Wyuna placedhigh workloads on the master and mate whowere performing the functions of instructorsas well as pilots.
The master was engaged in some form ofactivity related to training of the students andthe operation of the vessel whenever he wasawake. He was overseeing the pilotageoperations, monitoring the students andconducting or preparing for training. Theprogram aboard Wyuna was scheduled toattempt to ensure that staff receivedappropriate rest periods, but the hours of workimpacted heavily on the master. He was on the8–12 watch by day and night and he had othertasks outside these hours. Despite this,however, he felt that he was sufficientlyrested.
Reviewing the master’s operational hours fromthe start of the program with the Master ClassI students, it was determined that he had beenworking about twelve hours each day for thepast 3 days, suggesting that fatigue mighthave affected his judgement and performance.
Fatigue can have a detrimental effect on anindividual’s performance. It can affect aperson’s attention, memory, reaction time andthe ability to make decisions without the
person necessarily feeling fatigued. Thepossibility that fatigue might have been afactor in this incident was assessed using thecomputer program FAID 330E fromInterdynamics Pty Ltd. Two sets of data wereanalysed using this program.
The master’s hours of work and all otheractivities, other than times when he wasasleep, were utilised in the first set of datathat was analysed. The results of this analysiswere that high to very high fatigue scoreswere obtained for a number of days precedingthe incident. At the time of the incident, hisfatigue score was between high and very high,suggesting that fatigue may have been acontributory factor in the incident.
The other set of data used in the analysis wasfrom the master’s actual hours of duty only.The result of this analysis was that there werestandard to moderate levels of fatigue at themost demanding periods of work. At the timeof the incident, the master’s fatigue score wasbetween standard and moderate.
The Inspector has taken note of both analyses,but concludes that the master displayed anumber of symptoms which suggest thatfatigue may have affected his judgement. Hehad a preoccupation with the tide off BarrelSpit, to the exclusion of other visual cues.Although he could have checked the ship’sposition using ECS, he did not do so on thisoccasion. He was confused, thinking that thevessel was north of its actual position.
Ship management Wyuna was owned and operated by the AMCand it is the College that is ultimatelyresponsible for the safe operation of thevessel. The master was effectively the shipmanager and responsible to the AMC.
It would be reasonable to expect a traininginstitution to have a system of managementthat treated the ship as a ship rather than asjust another facility. Such a system is providedby the International Safety Management(ISM) Code.
Although Wyuna was not a vessel to which theISM Code applied, the ISM Code is a safetymanagement tool to:
• Provide for safe practices in ship operationand a safe working environment.
• Establish safeguards against all identifiedrisks.
• Continuously improve the safetymanagement skills of personnel ashore andaboard ship, including preparing foremergencies related both to safety andenvironmental protection.
The nautical complement of officers on boardwas not sufficient to maintain safe 24-hour operations, particularly in pilotagewaters. Although the master’s instructions tothe students contained the provision for aqualified person to be on the control bridgeduring pilotage exercises, this practice was notfollowed.
Although the master and mate conductedlectures and courses in addition to theirwatches and ship-keeping duties, there was noprogram to monitor possible fatigue.
Wyuna was managed in the same manner asother facilities and the AMC seemed toexercise little control over the vessel and itsoperations. Responsibility for the vesselseemed to have been almost entirely delegatedto the master.
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FIGURE 5:Grounding: Wyuna, Events and causal factors chart
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Events
Conditions
Incident
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ConclusionsThese conclusions identify the differentfactors contributing to the incident and shouldnot be read as apportioning blame or liabilityto any particular individual or organisation.
Based on the evidence available, the followingfactors are considered to have contributed tothe incident:
• There was insufficient oversight by theAMC of the operation of the vessel.
• Contrary to the advice in the students’notes, there was no officer on the controlbridge ready to assume control of thesteering and engines.
• The absence of clear written instructionscontributed to misunderstanding withrespect to who on the bridge had conductof the vessel.
• Fatigue may have resulted in the master’spreoccupation with the direction of flow ofthe tide across the channel. Fatigue mayalso have resulted in his loss of concen-tration, his inability to identify the vessel’sposition, the setting of an incorrect courseand his insistence that the course bemaintained.
• The student ‘master’ was aware of thecorrect course required and though he hadtime, in accordance with the principles ofBRM, to alert the master to the vessel’ssituation, he did not do so.
• The master did not receive adequatesupport from the student ‘OOW’.
• Even though the master had encouraged thestudents to question any divergence fromthe set plan, neither of the two students in aposition to challenge the master, did so.
• The student ‘OOW’ did not monitor thevessel’s progress as he should have. Had heused the radar as it was intended that heshould, he would have realised that thevessel was off course.
• The master dimmed the ECS display sothat the students were obliged to monitorthe ship’s progress visually and by radar,but this led to him also being unable to usethe ECS.
• Had the movement book or an equivalentsystem been maintained, the students wouldhave known of the ship’s position withrespect to beacons in the river.
• The echo sounder alarm, which was not inuse, would have provided an indication ofthe ship’s incursion into shallow water.
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These recommendations are publishedrecognising that corrective action may alreadyhave been taken to address the safety issuesidentified by the investigation.
The Inspector recommends that:
• The AMC document and implement anappropriate safety management system forthe operation of Wyuna.
• The AMC review manning levels for thevessel.
• A roster of duties for Wyuna be maintainedas well as a daily record of hours workedby each member of the ship’s crew tofacilitate the monitoring of fatigue levels ofindividuals.
• Clear unambiguous written instructions areformulated as part of the safetymanagement system to identify who hasconduct of the vessel at any given phase ofthe voyage.
Recommendations
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SubmissionsUnder sub-regulation 16(3) of the Navigation(Marine Casualty) Regulations, if a report, orpart of a report, relates to a person’s affairs toa material extent, the Inspector must, if it isreasonable to do so, give that person a copy ofthe report or the relevant part of the report.Sub-regulation 16(4) provides that such aperson may provide written comments orinformation relating to the report.
The final draft of the report, or relevant partsthereof, was sent to the master of Wyuna, theDirector of the Faculty of Engineering andMaritime Transport of the AMC and thestudents on the bridge at the time of theincident.
A submission was received from the Directorof the Faculty of Engineering and MaritimeTransport of the AMC and the report wasamended where necessary.
WyunaIMO Number 54393907
Flag Australian
Survey Authority Australian Maritime Safety Authority
Ship Type Training Vessel
Builder Ferguson Bros. Ltd, Port Glasgow
Year Built 1952
Owner Australian Maritime College
Gross Registered Tonnage 1 313
Net Tonnage 312
Displacement 1 831 tonnes
Maximum Draught 5.0 m
Length overall 63.5 m
Breadth 11.9 m
Engines 2 x 515 kW English Electric 400 V D.C. motors each driving a fixed pitch propeller
Generators 3 x 476 kW English Electric 400 V D.C. main diesel generators, plus 6 aux 220 V D.C. diesel generators
Maximum speed 13 knots with 3 main generators running
Crew 7 regular + 38 training and other berths
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AT
SB
Transp
ort S
afety Rep
ort
Marine O
ccurrence Investigation
Grounding of the A
ustralian flag training vessel Wyuna,
19 October 2000
161 Final
Investigatio
n
Australian Transport Safety Bureau
24 Hours 1800 020 616 Web www.atsb.gov.auTwitter @ATSBinfoEmail [email protected]