MARINE SAFETY INVESTIGATION

REPORT 181

Independent investigation into the grounding ofthe Liberian registered container ship

in Moreton Bay, Queensland19 July 2002

ANL Excellence

Department of Transport and Regional Services

Australian Transport Safety Bureau

Navigation (Marine Casualty) Regulations investigation into thegrounding of the Liberian registered container ship

ANL Excellence

in Moreton Bay, Queensland19 July 2002

Report No. 181

May 2003

ISSN 1447-087XISBN 1 877071 32 3

Investigations into marine casualties occurring within the Commonwealth's jurisdiction are conductedunder the provisions of the Navigation (Marine Casualty) Regulations, made pursuant to subsections425 (1) (ea) and 425 (1AAA) of the Navigation Act 1912. The Regulations provide discretionarypowers to the Inspector to investigate incidents as defined by the Regulations. Where an investigationis undertaken, the Inspector must submit a report to the Executive Director of the Australian TransportSafety 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 marineenvironment.

To increase the value of the safety material presented in this report, readers are encouraged to copy orreprint the material, in part or in whole, for further distribution, but should acknowledge the source.Additional copies of the report can be downloaded from the Bureau’s website www.atsb.gov.au

Australian Transport Safety BureauPO Box 967Civic Square ACT 2608 AUSTRALIA

Phone: 02 6274 64781800 621 372

Fax: 02 6274 6699E-mail: marine@atsb.gov.au

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Contents

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Sources of Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Narrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Brisbane Marine Pilots . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

The pilot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

The incident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

Comment and Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

The grounding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

The channel marking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

The pilot’s electronic chart system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Preventative measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

Bridge Resource Management during the pilotage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

Vessel Traffic Service Centre . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

Fatigue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Drugs and Alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

Safety actions already initiated . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

Submissions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

ANL Excellence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

Figures1. ANL Excellence aground in Moreton Bay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .iv

2. ANL Excellence’s position of grounding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

3. Master’s fatigue index plot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

4. Mate’s fatigue index plot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

5. ANL Excellence: Events and causal factors chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

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Figure 1:ANL Excellence aground in Moreton Bay

SummaryAt 0318 on 19 July 2002, the Liberian flagcontainer ship ANL Excellence embarked a pilotoff Point Cartwright, Queensland, for thepassage to Fisherman Islands container terminalin the Port of Brisbane. After arriving on thebridge, the pilot set up a portable electronicchart display equipped with a differential globalpositioning system, to allow him toindependently monitor the passage to the berth.

The pilotage proceeded routinely. There were noother movements within the port or theapproach channels during this time. The weatherwas reasonable, though visibility was reduced attimes by passing rain showers.

At 0518, ANL Excellence passed beacon E1 andentered the East Channel. Rain was falling atthis time and the bridge window wipers wereoperating. Ahead, the starboard lateral beaconE3 and the port lateral beacons E2 and E4 couldbe seen. A temporary, starboard lateral buoy wasmarking the position of the cardinal beacon E5which had been destroyed by a ship some 15 months previously. This temporary buoy wasnot seen by anyone on the bridge.

As the vessel passed starboard lateral beaconE3, the pilot ordered starboard rudder to bringthe ship to a heading of 240° and then calledBrisbane Port Control to advise that the shipwould be at the entrance channel at 0600.

The master, sitting in front of one of the tworadars, realised that the relative bearings ofbeacons E4 and E2 were changing and went tothe helmsman to see what was happening. Thepilot went to his electronic chart system, whichhad reverted to a blank screen stand-by mode.He tapped a key and when the chart wasrestored he suddenly realised that he hadordered the course alteration too soon.

The main engine was stopped and put astern,but ANL Excellence grounded before the shiphad begun to slow.

The ship was refloated on the high tide of theafternoon of 19 July 2002, using its main engineand with the aid of tugs. Following aninspection of the hull, both internally andexternally on 20 July, the vessel was cleared bythe Australian Maritime Safety Authority, andits classification society to continue in service.

The report conclusions include:

• The pilot did not follow his normalprocedure of checking the position of thecourse alteration using his portableelectronic chart system.

• The temporary buoy marking the originalposition of the original east cardinal beaconE5 (the turning mark) was obscured by rain.

• The green light on the temporary buoy wasnot as conspicuous as a white light, whichwould normally be associated with a cardinalnavigation mark.

• Although not suffering from chronic fatigue,the pilot’s performance was probablyaffected by the trough in his circadianrhythm associated with the hours between0400 and 0600.

• The pilot’s electronic chart system wasplaced at a significant distance from wherehe was standing, with its display in powersaving mode at a critical moment.

• The bridge team did not detect the erroneoushelm order and failed to challenge the pilot.

The report recommends that:

• Where port authorities use a buoy or othertemporary aid to replace an establishednavigation aid, the shape and the lightcharacteristics of the temporary aid should beconsistent with those of the aid it replaces.

• Brisbane Marine Pilots should review thepower management settings and placementof a pilot’s portable electronic chart systemto ensure that the information displayedremains easily visible from the pilot’sconning position at all times during apilotage.

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Sources ofinformationThe pilot

The master, mate and helmsman of ANLExcellence

Brisbane Marine Pilots

Brisbane Port Authority

Queensland Transport

ReferencesThe International Convention on Standards ofTraining, Certification and Watchkeeping forSeafarers 1995 (STCW), the InternationalMaritime Organization (IMO).

The Mariner’s Handbook, seventh edition, TheHydrographer of the Navy, U.K.

Bridge Instructions, Swedish Club.

AcknowledgmentsPhotographs of ANL Excellence in Moreton Baysupplied by the Courier Mail newspaper,Brisbane.

Certain reproductions of chart sections in thispublication are reproduced by permission of TheAustralian Hydrographic Service.

© Commonwealth of Australia 1973. 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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NarrativeThe Liberian flag, cellular container ship ANLExcellence, (figure 1), is owned by HansaAfrica Corporation of Liberia and managed byLeonhardt and Blumberg of Hamburg. It wasdelivered from its builders, Samsung HeavyIndustries, in June 1997, as Ibn Zaidoun underthe German flag. In May 2000 the name of thevessel was changed to Ville de Venus and, inJune 2001, the vessel changed flag to Liberia. InJanuary 2002 it was renamed ANL Excellence.The ship was built under Germanischer Lloyd(GL) class and has remained in GL class since.

The ship is 242.82 m in length with a beam of32.2 m, a moulded depth of 14.78 m and asummer draught of 11.717 m at a deadweight of42 953.6 tonnes. The vessel has the capacity tocarry 3 424 TEU1.

The ship is powered by a Samsung-Sulzer7RTA84C two-stroke, single-acting, directreversing main engine of 28 371 kW whichdrives a single propeller to give a service speedof 23.3 knots.

ANL Excellence’s wheelhouse is combined withthe chart room and communications area. Thelatter areas are partitioned off by curtains atnight. The steering position is on the centre lineof the wheelhouse behind an integrated controlconsole. The control console has alarm panels,engine and bow thruster controls, and three CRTdisplays. The centre display is a ‘ship statusdisplay’, which may be used to display criticalengine room information or an electronicnavigation chart. Either side of the ship statusdisplay are two radar screens. Chairs for themaster and officer of the watch are sitedimmediately behind the radar displays. Thebridge front is 178.7 m from the stem and 64.1 m from the stern of the ship.

At the time of the incident, ANL Excellence hada crew of 20 comprising the master and threedeck officers, the chief and three engineers, aboatswain and five seamen, three engine roomratings, two catering staff and a trainee. Themaster and mate were Russian nationals and theother officers were European. All of the ratingswere from Kirabati.

The master had been in command of ANLExcellence for about six weeks and had visitedBrisbane in June 2002. He graduated from theLeningrad High Marine Engineering College in1989 and had worked for a number of shippingcompanies on general cargo, multipurpose, rollon/roll off and container ships. He gained hismaster’s certificate in 1997 and was promotedto master in 1998. As part of his training, themaster had undertaken a course in Canada,which included elements of Bridge ResourceManagement, consistent with the requirementsof STCW 952.

The mate qualified as a deck officer in 1985.She had experience on refrigerated cargo shipsand container ships and held a chief mate’scertificate of competency. She had joined ANLExcellence as second mate in January 2002 andwas promoted to chief mate in May.

At the time of the incident, ANL Excellence wasoperating on a scheduled container servicebetween Port Klang in Malaysia, Singapore,Brisbane, Sydney, Melbourne, Adelaide andFremantle. The ship had completed fourvoyages, each of four weeks duration, sinceMarch 2002.

Brisbane Marine PilotsBrisbane Marine Pilots (BMP) is the companywhich provides pilot services for the Port ofBrisbane. The company operates an ‘ondemand’ pilot service under contract toQueensland Transport.

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1 TEU Twenty foot container equivalent unit.

2 International Convention on the Standards of Training, Certification and Watchkeeping for Seafarers 1995.

BMP pilots work a cycling duty roster ofsixteen days with ten days duty followed by sixdays leave. The number of pilots on the dutyroster is dictated by normal traffic patterns inconjunction with the company’s fatiguemanagement policy. To minimise the risk ofpilots being affected by fatigue, BMP operate arisk monitoring system based on a fatiguemodelling computer program. This system issupplemented by ‘Pilot Job Allocation’guidelines, which are used by the pilotoperations coordinators when assigning pilots toships. These guidelines suggest a minimumperiod of eight hours between ships (includingan hour each way for travel plus a six hourbreak).

BMP’s Fatigue Audit InterDyne (FAID) fatiguemodelling program, was developed byInterdynamics in collaborative partnership withthe Centre for Sleep Research at the Universityof South Australia. The FAID programquantifies an individual’s level of fatigue basedon hours of work for the previous seven days.Pilot’s duty hours, including travel, are enteredinto the computer program which returns a‘fatigue index score’ for each pilot at any giventime. BMP have set an index score of 80 as thebenchmark to indicate that a pilot’s performancecould be adversely affected by the rostered dutyand the pattern of work hours. Should pilotsexceed this score they are considered to beentering a risk zone for fatigue.

As a part of their normal shipboard operatingprocedures, BMP pilots carry a portableelectronic charting system (ECS) on a lap topcomputer, which utilises a differential globalpositioning system (DGPS) receiver for positioninformation. The ship’s real time position isplotted automatically every ten seconds, and,together with the course made good and theship’s speed, is stored in a memory file. Thesystem is independent of the ship’s navigationequipment and allows the pilot to monitor theship’s position in relation to the passage plan atany time. The portable ECS units carried by the

pilots are not intended to replace ship’snavigation equipment, rather they are to be usedin conjunction with conventional aids such asradar and properly corrected navigation charts.

The pilotThe pilot assigned to ANL Excellence on 19 July 2002 joined BMP in June 1999. Hegained a restricted pilot’s license for the port on5 August 1999. In January 2002 he gained anunlimited license and, as such, wasappropriately qualified to have the conduct ofANL Excellence in the Brisbane pilotage district.He had piloted more than 400 ships in his timewith BMP.

At the time of the incident the pilot also held amaster class 1 certificate of competency issuedby the Australian Maritime Safety Authority. Hehad extensive experience as a seagoing deckofficer and master and had pilotage experiencein south pacific and other Australian ports.

On 18 July the pilot had just completed a sevenday period of leave, as part of his normal dutycycle. His normal routine on days off was to getup at about 0600 and go to bed between 2230and 2300. It was not his habit to sleep in theafternoon on his days off.

The pilot started his first day back at 0600 on18 July. At 0900 he telephoned the BMP officeand was told that he had been assigned to ANL Excellence with an anticipated boardingtime of 0300 on 19 July. He then busied himselfwith jobs at home for the day. His assignment toANL Excellence was confirmed at 1600. Atabout 1800 he drove, in company with anotherpilot, to the pilot station at Point Cartwright,arriving at 1930.

After his colleague had left the pilot house, atabout 2030, the pilot went to bed at about 2100.He found it difficult to sleep, but did eventuallysleep, waking for a brief period at aboutmidnight. He was woken, as requested, at 0230on 19 July to join ANL Excellence.

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The incidentANL Excellence sailed from Port Klang on 10 July 2002 and completed its sea passage offPoint Cartwright at 0248 on 19 July 2002.

At 0318, the pilot from BMP boarded the vesseloff Caloundra Head. The master and pilotexchanged information regarding the ship, theinward passage and the berthing manoeuvre.

The pilot confirmed that the ship was to enterMoreton Bay by the deep-water route, throughNorth West Channel, Spitfire Channel, MainChannel and East Channel. With the ship’smaximum arrival draught of 11.7 m, this routewould provide a minimum under keel clearanceof 3 m for the passage to the berth. As part ofthe initial exchange of information the pilotinvited the ship’s staff to challenge any order hegave, if they were unsure of his plan of action.The master, in turn, told the pilot of an apparentsteering problem the ship had experienced whileen route through the Great Barrier Reef. Heindicated that he was not sure if the problemhad been the result of the ship’s limited underkeel clearance or poor steering by thehelmsmen.

During this time the pilot set up his portableelectronic chart system on a table on thestarboard side of the wheelhouse, adjacent to theonly convenient power outlet.

At 0338 the pilot called Brisbane HarbourControl, confirming the ship’s draughts andarrival time.

At 0345, after the pilot assumed the conduct ofthe vessel, ANL Excellence passed the fairwaybuoy inward. Two ratings where acting ashelmsmen, alternating every hour on the wheel.Two steering motors were in operation for thepilotage and the pilot felt that there was nodifficulty steering the ship. He felt that theresponse to the rudder was normal for the typeof ship.

At 0400 the mate relieved the second mate asofficer of the watch. The tide was just past highwater and was virtually slack. The wind wassouth-easterly at 10 knots. The visibility enteredin the log book was described as ‘good,moderate in intermittent rain, vessel rollingmoderately’.

The passage proceeded routinely. After passingthe number three beacon in the North Westchannel (NW3), the main engine revolutionswere increased to full sea speed (85 rpm) toensure arrival at the Entrance Beacons by 0600.The mate recorded the time of passing eachbuoy on the chart and in the bell book. Thevessel rounded NW12 beacon into SpitfireChannel at 0442. In Spitfire Channel the pilotremarked to the master that the computergenerated positions of the beacons, displayed onthe ship’s electronic chart system, wereinaccurate.

At 0451 the ship entered the Main Channel. Atthis time the ship encountered intermittent lightrain necessitating the use of the bridge windowwipers.

ANL Excellence entered East Channel on aheading of 190° (T) at 0518. The ship’s speedshown on the GPS was varying between 18 and19 knots. The master crossed to the table wherethe pilot’s electronic chart system was showingthe ship’s passage and briefly discussed thedisplay and its effectiveness with the pilot. Upto this time during the passage, the pilot hadchecked the electronic chart system beforeordering each alteration of course.

At around this time, beacon E3, showing agreen light flashing every 4 seconds, could beseen to starboard and the port hand beacons, E2and E4, could be seen on the port bow bothshowing red lights. A temporary lateralstarboard-hand buoy marking the south-eastextremity of Middle Bank could not be seenvisually, as it was obscured by a passing rainshower.

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Figure 2:ANL Excellence’s position of grounding

Position of grounding

0518

0511

0520

0500

0525

134°

170°182°

191°

ACT

NSW

NT

Qld

WA

SA

Vic

Tas

NT

NSW

ACT

Location ofincident

ANL Excellence’s approximatetrack 19 July 2002

Planned passage

The master resumed his seat in the chair in frontof the port radar display. The pilot was standingto the starboard side, between the controlconsole and the table on which his electronicchart system was located. On the ship’s console,the central ‘ship status screen’ was showingengine operating parameters. During this timethe mate spent much of her time in the charttable area, only coming to the forward part ofthe bridge to check the time of passing eachbuoy or beacon.

At about 0525, the pilot ordered 10° ofstarboard rudder, then an easing of the rudderangle to 5°. Standing close to the helmsman’sright hand side, he ordered the helmsman tosteer a course of 240°, his normal course fromnumber five East Channel beacon to theEntrance Channel beacons for the Port ofBrisbane. The pilot then made radio contactwith Brisbane Port Control tower. The exchangetook 15 seconds:

Pilot: Brisbane Harbour – ANL Excellence –that’s 30 minutes to the Entrance Beacon.

VTS: ANL Excellence – Brisbane Harbour –Romeo – Captain they don’t want you alongsidebefore seven.

Pilot: There’s no danger of that.

VTS: Brisbane Harbour - Romeo

During this time the master was watching theport radar display while the mate was using thestarboard radar to check the time of passing thebeacons. Both radars were set on the three-milerange. At 0525 the mate looked at the starboardradar and went to the chart table to enter thetime of passing E3 beacon to starboard in themovement book. She did not hear the pilot orderany course alteration.

The master, watching the port radar, heard thepilot give a series of orders to the helmsman:

Starboard ten; starboard five, steer 240°

About 20 seconds later he realised that therelative bearings of E2 and E4 beacons werechanging rapidly. He saw that the ship’s heading

was 210° and that the ship was swinging tostarboard with the speed reducing to 17.5 knotsdue to the turn. The master left his chair andwent to the helmsman, thinking that he hadmade some error. At the steering position hesaw the course was now 244°, but the pilot saidwords to the effect that the ship would settle oncourse.

The pilot moved towards his electronic chartsystem. The screen was blank as it had revertedto energy saving mode. He tapped a key on thekeyboard and the display was restored. Heimmediately realised that he had ordered thealteration of course at the wrong position.

The master recalled that the pilot said:

Oh captain! Oh my God, I missed the buoy

At this time the captain said:

OK lets go to starboard

To which the pilot replied:

No, stop engine…

the pilot explained that there was shoal water tostarboard. The engine telegraph was put to stop.

At 0528 all way came off the ship in position27° 13.28’S 153° 19.65’E, with the shipheading 246°. The ship was aground on MiddleBanks, 1.2 miles north-north-west of thetemporary buoy marking the position of the E5channel beacon (see fig. 2). The master andhelmsman felt that the ship seemed to surge as itdecelerated from 17.5 knots. It was one hourafter high water at Tangalooma Point with a tideheight of 1.6 m above datum.

At about 0528, the engine was put astern,initially on slow astern revolutions and progres-sively to full astern over a period of 21⁄2 minutes.At about 0531 the engine was put to full astern.There was some initial movement astern, but theship seemed to became fast again. Worried thatthe propeller wash would build up sand aroundthe midships section, the pilot ordered ‘stopengine’. The engine was stopped at about 0535.

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At 0541, the pilot reported the grounding to thePort Control Tower and requested the assistanceof two tugs. He also contacted the duty directorof Brisbane Marine Pilots.

The master instructed the mate to sound all ofthe ship’s tanks to establish whether theintegrity of the hull had been compromised. Thesecond mate was woken and was charged withsounding the water depth around the ship.

The soundings revealed that the ship was afloatforward and aft, but aground amidships with nosign that the hull had been breached.

At 0722 two tugs arrived at the ship and weremade fast. An attempt was made to refloat thevessel at this time and there was somemovement initially. At 0845 the attempt wasabandoned due to the falling tide.

At 0857 a relief pilot arrived on board followedby the Queensland Water Police, whobreathalysed the master and the pilot. The pilotthen returned to shore.

ANL Excellence was refloated on the rising tideat 1436 that afternoon, 19 July. The vessel wentto anchor and was examined both internally andexternally for any damage. The vessel remainedat anchor until the afternoon of 20 July when itberthed at Fisherman Islands container terminalto resume its service.

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Comment andanalysis

EvidenceThe pilot was interviewed ashore on 19 July byATSB investigators. He provided the investi-gators with a copy of his electronic chart systemfile for the pilotage on 19 July. This provided anaccurate real-time track and course made goodby ANL Excellence from the pilot embarkationpoint to the grounding. (A pilot is unable to alteror access the files recording the vessel’s track.)

Investigators interviewed the master, mate andhelmsman on board ANL Excellence andinspected the ship on 20 July. The accountsprovided by the master and pilot relating to theinward passage are consistent throughout,except for some minor differences at the time ofthe grounding.

The ship’s engine telegraph movements wereautomatically recorded. The automatic recorderwas about 14 minutes fast compared with thelocal time displayed on the ship’s GPS receiver.The ship was equipped with a course recorder,but it was not in operation during the inwardpilotage passage.

Port Control audio tapes were obtained andprovided time-stamped records of the actualVHF radio traffic to and from Port Control. Theclock used in recording the times of theserecordings was apparently between three andfour minutes fast.

The groundingOn 19 July 2002, ANL Excellence grounded onMiddle Banks in Moreton Bay as a result of asimple error of judgement on the part of thepilot. The pilot stated that he had ordered the

alteration at E3 beacon, a starboard hand lateralmark, by mistake.

At the time of the grounding it was still morethan an hour before sunrise with nauticaltwilight at 0541. The sky was overcast and so inthe absence of any natural light, the pilot wasreliant on the lights of the navigational aidsmarking the channel to visually indicate theship’s position in the East Channel. For somereason the E3 beacon (green, flashing at 4second intervals) provided an incorrect cue tothe pilot that the ship had reached the temporarybuoy (green, continuously flashing veryquickly) marking the position of the original E5east cardinal beacon (white, three very quickflashes every 5 seconds).

The distance between E1 and E5 beacons isabout 6050 m (3.23 miles) and between E1 andE3 beacons the distance is about 4100 m (2.22 miles). At 19 knots ANL Excellence wouldhave covered the distance between E1 and E5beacons in 10 minutes and 21 seconds. Thepilot, however, ordered the alteration of courseabout seven minutes after passing E1 beacon.

At, or approaching E3 beacon, the pilotapparently missed several visual and time cuesand adopted his usual routine as though the shipwas passing E5 beacon. The pilot said that,although he could not see the temporary buoymarking the position of E5 Beacon, he could seethe lateral beacons E2 and E4 on the port sideahead of the ship. Despite this, he still orderedthe course alteration and called port control togive them the ship’s estimated time of arrival atthe Entrance Beacons. He did not, however,check the ship’s position using the ship’snavigation aids or the portable electronic chartsystem, which was his usual practice, prior toordering a course change. In the time leading upto the course alteration, the pilot was engaged inconversation with the master and it appears thatwhen he ordered starboard rudder, for whateverreason, the pilot had lost his awareness of theship’s actual situation.

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The channel markingOn 21 April 2001, the container ship MaksimMikhaylov (ATSB report number 168) madeheavy contact with the east cardinal lightbeacon E5, effectively destroying the beacon.Queensland Transport (the State governmentdepartment responsible for the operation of theport) established a starboard lateral light buoy inits place. This was promulgated by QueenslandTransport notice 179(T)/2001 of 16 May 2001,which was superseded by 198(T)/2001 of 18 May 2001. The Australian HydrographicOffice promulgated the change in Edition 12 ofthe Australian Notice to Mariners of 8 June2001, notice 333(T)/2001.

In July 2001, a second navigation light inMoreton Bay was destroyed by an unidentifiedvessel. This light was the rear leading light (rearreciprocal) of the Entrance Channel leads.

During the year Brisbane Marine Pilots raisedthe issue and timing of the reinstatement ofbeacon E5, and the withdrawal of the temporarylateral buoy, with the harbour master. The issuewas raised formally and minuted at threemeetings between the regional harbour masterand the directors of BMP. At a meeting on 4 December 2001 it was anticipated that beaconE5 would be replaced early in 2002. In late2001, Queensland Transport decided that asingle contract should be drawn up covering thereplacement of both navigation aids as a singleproject, as this would be the most economicalcourse.

At a meeting between the parties on 21 February, the harbour master expected thereplacement of both beacons to be completed inJune or July 2002. At a later meeting on 10 May, the anticipated date of completion forreplacing the two navigation aids was furtheramended to October 2002.

The green lateral buoy in place of the originalE5 beacon had a major disadvantage in thatgreen lights are not as visible or conspicuous as

white lights and the green light did not indicatea cardinal mark. The temporary light buoyexhibited the same colour light as E3 beacon,however its interval was markedly different(VQG). In addition, the buoy was not equippedwith a radar reflector.

The ship’s staff were not aware of the temporarychange to the navigation mark at the south-eastextremity of Middle Banks. ANL Excellencereceived its chart corrections through the UKHydrographic Office. The charts in use werecorrected to the latest edition of the AdmiraltyNotice to Mariners received on board. Theinformation concerning the temporaryreplacement of beacon E5 was contained inAdmiralty Notice to Mariners Weekly Edition25 of 21 June 2001, as a correction to Volume Kof the Admiralty List of Lights and Fog Signals.There was no temporary notice promulgated forchart AUS 236 through the British notices.

The Mariner’s Handbook, published by theUnited Kingdom Hydrographic Office details inChapter 1 issues of chart correction and safetycritical information. The chapter notes theproliferation of temporary changes to navigationaids and notes:

1.55

… Information that does not warrant a Noticemay have to await the next edition. AdmiraltySailing Directions, Admiralty List of Lights, andAdmiralty List of Radio Signals can be correctedmore frequently than major corrections can bemade to charts, and should be carefully examinedin conjunction with the chart.

1.66

… Note A (T)NM will not normally be initiatedwhere the information will be valid for less than3-6 months. In such cases this information maybe available as an RNW (1.56) or a local Noticeto Mariners.

The chart in use aboard ANL Excellence at thetime of the incident indicated that beacon E5was still in situ.

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A pilot is engaged for his/her local knowledge,including temporary changes in the portenvironment. The pilot on board ANLExcellence was fully aware of the temporarychange to the navigational aids marking the EastChannel, specifically the temporary buoy whichhad been marking the position of the E5 beaconfor the previous 15 months. He was also fullyaware that the light characteristics of E3 beaconwere different in colour and characteristic fromthe original cardinal beacon. During the initialinformation exchange the pilot made no checkto ensure the ship’s chart had been corrected nordid he inform the crew of the temporary changeto the navigation aid.

On the inward passage all beacons wereshowing good target returns on the ship’s radar.The temporary buoy was not displayed on theradar or was not obvious. Beacons E2 and E4were visible to port but the buoy marking theposition of beacon E5 was obscured by rain.The passing rain shower temporarily removed apotentially important visual prompt that mayhave alerted the pilot, master or mate to thecorrect alteration point, or immediately alertedthe master that the ship was leaving the channel.

The probability is that had beacon E5 been inplace, or a temporary buoy with a conspicuouswhite light been used as a temporary mark, itwould have provided a dominant cue and thepilot would not have altered course at beaconE3.

The pilot’s electronic chartsystemIn their submission, Queensland Transport notedthat the electronic chart system carried by thepilot has no official endorsement as a naviga-tional tool and, while recognising the system’sutility, considers that it should not be acceptedas an alternative to the conventional approvedmethods of navigation in confined waters.

Pilots do not usually navigate in the sense offixing a ship’s position on a chart and thensetting a new course, generally time does not

allow for this. Using their local knowledge, apilot conducts the ship by monitoring itsposition within the fairway to keep it withinsafe water. A pilot should recognise his/hersurroundings without reference to the chart,either by recognising navigation marks, orlandmarks, or, when circumstances require,being familiar with radar pictures.

While accepting, where appropriate, pilots mayuse radar to confirm the ship’s position, the ECScarried by the BMP pilots is a very accuratesystem. Both are aids to assist the pilot. Aproperly set up ECS provides the pilot withinstant confirmation of his visual assessment ofthe ship’s position. The ECS also provides anaccurate forecast of the ship’s position if acertain course and speed is maintained. TheECS has the advantage of being the pilot’sequipment and thus provides information, whichhe knows is of consistent quality.

The pilot did not use his ECS to confirm theship’s position before altering course, althoughhe stated that it was his normal practice to doso, was a factor which contributed to thegrounding. He assumed that the ship was in aposition off the E5 Beacon and in his mind hadno need to check any of the ship’s navigationalequipment including the radars or chart. Whenhe went to his lap top computer, after he hadordered the course alteration, it had reverted to ablank screen.

A pilot’s main tool remains his/her visual acuity,detailed knowledge of the pilotage area and shiphandling skills. While radar and ECS are usefultools they should be used to support a pilot’sdecision making process, not as a substitute.

The pilot’s lap top computer was placed in thestarboard corner of the wheelhouse, about sevenmetres from the centre line and about fivemetres from where the pilot was standing.Where he placed the unit was dictated by theposition of a convenient power outlet. Had thelap top been closer to the pilot’s normal conningposition he would probably have been moreinclined to refer to the ECS. This grounding is

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the second accident in Moreton Bay in whichthe ECS was placed away from the pilot’snormal conning position.

In submission BMP stated:

BMP does not endorse or require pilots to placetheir ECS in any nominated position whilstconning the vessel. The position of the ECS doesnot necessarily contribute or detract from theoverall performance of the pilot’s duties. There isno normal position per se; in most cases, theposition for the ECS will be determined by powersocket location, safe position, glare from the sun,etc. In other words, the position of the ECSshould not adversely impact on a pilot’s ability toreference this equipment.

In addition, the fact that the system can revert toa power saving mode at a potentially criticalmoment is a weakness in the system. The screensaver is programmed by the user, as is the harddisk sleep function. The pilot had the screensaver set at 15 minutes and the hard disk powerdown at 30 minutes. Such settings may benecessary to save power when operating onbatteries. When operating on mains power thereis no reason to have any limitation on thedisplay time. Appropriate use of the computer’spower management system would allow thepilot to select different settings for the when thelap top is using mains or battery power.

Preventative measuresThe act of a ship entering the confines of a portinvolves interaction between the ship’s crew andport services often with specialist navigationassistance provided by a pilot. The way inwhich the parties interact is defined by variousconventions and rules whose purpose, amongother things, is to effect the safe passage of theship to the berth. In any such ‘system’, thereshould be sufficient safeguards or defences toprevent an oversight or error on the part of anyindividual leading to catastrophic consequences.

On the morning of 19 July 2002, there weredefences which may have prevented ANL Excellence from grounding as a result ofthe pilot’s order to alter course prematurely.

Effective passage monitoring by the masterand/or mate would have allowed the pilot’sorder for the premature course alteration to bechallenged or countermanded. In addition, withVTS radar coverage of the area, there was alsothe possibility of a warning from Brisbane portcontrol when the ship deviated from thestandard track. Given the speed of the ship andthe proximity of shoal water west of beacon E3,any such action would need to have beenvirtually immediate.

Bridge Resource Managementduring the pilotageOn the morning of 19 July, the pilot was able toorder an erroneous course alteration althoughthe intended passage and alteration off theposition of E5 Beacon was understood by themaster and mate and was programmed into theship’s radar. The pilot’s order off E3 Beaconwas executed without any crosscheck orchallenge. Neither the master nor mate checkedthe ship’s position at the time. The groundingbecame inevitable before the pilot’s error wasdetected by either member of the ship’s bridgeteam.

During the initial pilot/master informationexchange the pilot provided the master with afull plan of the inward passage. He also invitedthe master and mate to ‘challenge’ him if therewas any order that he gave, or aspect of theconduct of the vessel, about which they wereconcerned. This part of the interchange betweenthe pilot and the bridge team was consistentwith the ship’s own procedures.

The shipping company’s standing orderscovering bridge procedures referred to ‘BridgeInstructions’ published by the Swedish Club.These general instructions introduce the conceptof ship’s deck officers adopting an aviationpilot/co-pilot approach when working as anavigation team in conditions of intense orrestricted navigation. This section of theinstructions does not refer specifically to timeswhen a port pilot is on board but rather to

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situations requiring a high degree of attentionover a prolonged period.

In the section on ‘Navigation with a Pilot OnBoard’, the Swedish Club’s ‘BridgeInstructions’ stress that the duties andobligations of the master and officer of thewatch are in no way diminished by the presenceof a harbour or sea pilot. The guidelines requireclose cooperation between the officer of thewatch and the pilot and emphasise the idea of‘challenge’ when the limits of the passage planare exceeded or there are doubts about thepilot’s actions. They also require that the officerof the watch ensures that the steering andengine orders are executed according to thepilot’s orders.

The evidence is that the mate habitually spentprolonged periods in the chart room. Other thanentering the ship’s position and engine orders inthe bell book she took no part in monitoring theconduct of the ship or monitoring the pilot’sactions. She was newly promoted and it wasapparent that the relationship between themaster and mate was strained. The impressiongained from the interviews was that she wasanxious to minimise direct contact betweenherself and the master.

This interpersonal tension effectively nullifiedthe active participation of one qualifiednavigator in the bridge team.

During the initial information exchange themaster provided the pilot with details of the shipand brought to his attention a possible steeringproblem. The ship had also prepared a ‘BrisbanePilot to Brisbane Port’ passage plan via the EastChannel, based on GPS waypoints, for thepassage to the berth. Waypoint 10, at 27°10.9’S153° 20.7’E, corresponds with a position 450 meast-south-east of beacon E1. The course fromthis point was noted as being 191°(T) with adistance to the next waypoint of 3.3 miles.Waypoint 11 was 450 m south-east of beaconE5, at 27° 14.1’S 153° 20.0’E.

The two radars were set to the three mile range,giving a radar scan of 7 minutes and 50 secondsahead of the bow. The waypoints and thecourses between the waypoints were generatedon the radar screens. The proposed route wasshown as a fixed red line.

Passing beacon E3 the visibility was moderate,with some restriction due to rain. The mate wasat the forward part of the bridge as the vesselapproached E3 beacon, close to the starboardradar. She returned to the chart table to enter thetime of passing the beacon in the bell book. Shestated that she did not hear the pilot’s order tothe helmsman for starboard rudder.

The master was aware of the pilot’s order forstarboard 10° rudder and then starboard 5° rudder. The ship was making headway atabout 18.5 knots (571 m/min, 9.52 m/sec). Themaster was not using a parallel index techniqueon the radar to monitor the ship’s position in thechannel although the projected course wasdisplayed on the radar as a red line. When heheard the pilot give the order to the helmsmanat about 0525 (based on the pilot’s portableelectronic chart system the actual time wasprobably 0524:40), the master did notimmediately associate the order with thealteration of course. He was not anticipating thealteration, although he could not see any beaconor navigation mark ahead to starboard.

When the master became aware that the relativebearings of beacons E2 and E4 were changingunexpectedly his first thought was that thehelmsman had made an error. He recalled thatthe course was about 210° by gyro when herealised the ship was in the process of asubstantial course alteration. Between 30 and 40 seconds had elapsed since the alteration ofcourse had been ordered and between 20 and 30 seconds after the ship responded to the order.

By this time the ship was turning rapidly tostarboard at about 36°/min under a small angleof rudder.

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Given the master’s relatively slow reaction tothe pilot’s order for the course change, it isdoubtful that he had full situational awarenessof the ship’s navigation in the period leading upto the order. Given this situation and that factthat the mate was apparently not actively partic-ipating in the pilotage, the ship’s members ofthe bridge team were ineffective in preventingthe grounding.

Vessel Traffic Service CentreThe Brisbane Port Vessel Traffic Service Centrehas radar coverage of the whole of thecompulsory pilotage area. Pilots of inwardbound vessels routinely provide their ship’sestimated time of arrival (ETA) at the EntranceBeacons after clearing East Channel and while,or just after, altering course to about 240°.

ANL Excellence was the only pilotagemovement between 0300 and 0600. When thepilot called at 0525 the ship would have beenthe only sizeable movement on the radarcoverage. Had the port control VTS operatorrealised that the pilot was reporting his ETAearlier than normal and/or detected thealteration of course he would have been in aposition to warn the pilot that the ship wasstanding into danger.

The pilot’s evidence is that he made the call toport control after ordering the alteration. Themaster’s account of the incident supports thepilot’s account. Unfortunately the time of theVHF radio call is not accurately known as thetime stamps on the voice recordings were inerror by some minutes. When it was reset by aport officer the time difference between thecomputer time and UTC was not accuratelynoted.

It is not possible to assess whether or not thealteration of course was apparent on the VTSradar display at the time of the call. Therewould have been some delay before the VTSoperator could have recognised that the ship haddeparted from the usual track. Nor is it clear,with the turn established, whether a warning by

the VTS operator would have been in time toprevent the grounding.

At present the role fulfilled by VTS inQueensland ports is an information service. It isnot the job of the VTS operators to attempt toremotely pilot vessels. Their task is to advisepilots of other traffic and to act as a communi-cations hub. This does not, however, precludethe provision of warnings to pilots (inexceptional circumstances) by the VTSoperators who routinely monitor the passage ofships using their navigation channels.

Historically there has been some reluctance bypilots to accept advice from persons notqualified in pilotage. VTS operators have beenreluctant to warn pilots in case the pilot is fullyin command of the situation and is dismissive ofintervention from ashore. An unnecessary callmight also be a distraction to a pilot and theship’s bridge team during a critical time in amanoeuvre. Often ships are operating inrestricted waters and the opportunity foreffective intervention is very limited.

When exchanging radio messages a simpleradio protocol could help reduce the risk of anaccident. In future, when calling or called by aship, the VTS operator could identify the ship’sposition within the channel. In this case areference to beacon E3 may have been awarning to the pilot that he was altering at thewrong beacon.

Queensland Transport indicated that they werecurrently reviewing vessel traffic managementwith a view to enhancing the role of VTS tomake it more pro-active and interactive. Such arole may include the provision of advice toships under pilotage, however the responsibilityto act on any such advice will remain with themaster and/or pilot on the vessel.

In submission Queensland Transport stated withregard to the issue of VTS:

As the report correctly observes, the VTS is aninformation system only and is not equipped to

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provide instant off course alarms. And theVTSOs are not trained to carry out a higher levelfunction. The level of service being provided isunder review. However, any increase in the levelof service has considerable implications forequipment and training needs.

FatigueThe grounding occurred at a time of daycoinciding in a ‘trough’ in the human ‘circadianrhythm’, which has a negative affect onalertness; the hour before dawn is a timeassociated with a marked reduction in humanperformance.

The pilot had returned from a period of leave on18 July. ANL Excellence was his first ship onroster for a period of 8 days. He should havebeen refreshed and his performance unaffectedby any considerations of fatigue throughprolonged duty hours. With an early morningstart, initially 0200, he could have anticipatedthe need for rest. He did have an opportunity torest in the afternoon, however, if he was notinclined to sleep then he could not force it. Hedid sleep from about 2100 to midnight andagain after midnight but he would also havebeen affected to some degree by the ‘earlymorning effect’.

As the pilot’s duty roster developed, his hoursof work would have been subject to the BMPfatigue management system. However, giventhat the pilot had only been on roster for oneday, it would be difficult to extract a meaningfulscore from the FAID system for the purposes ofthis investigation.

In the case of the master and mate of ANL Excellence the FAID program is easier toapply. ANL Excellence had been on passagefrom Singapore, through the Great Barrier Reef.The ship had been maintaining normal seawatches since Singapore, but the master hadbeen on duty for extended and irregular hours asa result of the demands of the pilotage throughthe Great Barrier Reef and the arrival time offBrisbane. On 16, 17 and 18 July, particularly, hehad had less than six hours broken sleep each

day (see fig. 3). The mate, although maintainingwatches, had also worked extended hours partic-ularly on 14 and 15 July (see fig. 4).

FIGURE 3:Master’s fatigue index plot

FIGURE 4:Mate’s fatigue index plot

A score in excess of 80 indicates that fatiguemay start to affect performance. Both themaster’s and mate’s scores at 171 and 158respectively, were very high around the time ofthe incident with their pre-existing level offatigue compounded by the time of the day.

Fatigue degrades performance. The fact that themaster heard the pilot give an order to thehelmsman but was slow to realise theimplications of the alteration and that he firstchecked the helmsman, rather than query thepilot, is a sign of probable fatigue.

Drugs and AlcoholNeither prescribed, ‘over-the-counter’, or illicitdrugs, nor alcohol were a factor in thegrounding.

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ConclusionsThese conclusions identify the different factorscontributing to the incident and should not beread as apportioning blame or liability to anyparticular individual or organisation.

Based on the evidence available, ANLExcellence grounded on Middle Banks on 19 July 2002 as a result of the pilot erroneouslyordering an alteration of course at the starboardlateral beacon E3 instead of at the temporarystarboard lateral buoy marking the position ofthe original east cardinal beacon E5. Thefollowing are considered to be factors in theincident:

1. The pilot did not follow his normalprocedure of checking the position of thecourse alteration using his portableelectronic chart system.

2. The temporary buoy marking the originalposition of the original east cardinal beaconE5 (the turning mark) was obscured by rain.

3. The green light on the temporary buoy wasnot as conspicuous as a white light, whichwould normally be associated with a cardinalnavigation mark.

4. Although not suffering from chronic fatigue,the pilot’s performance was probablyaffected by the trough in his circadian

rhythm associated with the hours between0400 and 0600.

5. The pilot’s electronic chart system wasplaced at a significant distance from wherehe was standing, with its display in powersaving mode at a critical moment.

6. The bridge team did not detect the erroneoushelm order as a result of:

1. Both the master and mate were probablyfatigued as a result of their hours of workduring the passage through the GreatBarrier Reef, which was exacerbated bythe ‘time of day’ effect.

2. Neither the master nor the mate weresufficiently aware of the ship’s situation,at the time, to challenge the pilot’spremature order for the course alteration.

3. Insufficient attention was paid to theship’s radar display.

4. The navigation chart in use by the shipdid not show the temporary replacementof E5 cardinal beacon with a temporarystarboard lateral buoy marking the south-east extremity of Middle Bank.

5. The interpersonal tension between themaster and mate effectively nullified theactive participation of one qualifiednavigator in the bridge team.

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Safety actionsalreadyinitiatedQueensland Transport are in the process ofreviewing VTS management with a view tomaking the system more interactive andproactive.

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MR20030022Where port authorities use a buoy or othertemporary aid to replace an establishednavigation aid, the shape and the light character-istics of the temporary aid should be consistentwith those of the aid it replaces.

MR20030023Brisbane Marine Pilots should review the powermanagement settings and placement of a pilot’sportable electronic chart system to ensure thatthe information displayed remains easily visiblefrom the pilot’s conning position at all timesduring a pilotage.

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Recommendations

SubmissionsUnder sub-regulation 16(3) of the Navigation(Marine Casualty) Regulations, if a report, orpart of a report, relates to a person’s affairs to amaterial 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 a personmay provide written comments or informationrelating to the report.

The final draft of the report, or relevant partsthereof, was sent to the master, mate, pilot, theship’s management company, QueenslandTransport, Brisbane Marine Pilots and theAustralian Maritime Safety Authority.

Submissions were received from BrisbaneMarine Pilots and Queensland Transport andwhere appropriate, the report text has beenamended and portions of the submissionsincluded.

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ANL ExcellenceFormer Names Ibn Zaidoun – 1997, Ville de Venus – 2000

IMO Number 9134517

Flag Liberia

Port of Registry Monrovia

Classification Society Germanischer Lloyd (GL)

Ship Type Cellular container ship

Builder Samsung Heavy Industries, Korea

Year Built 1997

Owners Hansa Africa Corporation

Ship Managers Leonhardt and Blumberg

Gross Tonnage 37 394

Net Tonnage 20 334

Deadweight (summer) 42 953.6 tonnes

Summer draught 11.717 m

Length overall 227.93 m

Breadth 32.20 m

Moulded depth 14.78 m

Engine Samsung-Sulzer 7RTA84C, two-stroke, single acting, direct reversing.

Total power 28 350 kW

Crew 20 (Russia, Ukraine, Kirabati, German)

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72 Independent investigation into the grounding of the Liberian registered container shipANL Excellence in M

orton Bay, Queensland 19 July 2002

ISS

N 1447-087X

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N 1 877071 32 3

ANL Excellence. 05.03