MARINE SAFETY INVESTIGATION

REPORT 169

Independent investigation into the grounding ofthe Kerguelen Islands (French) registered

in Port Phillip Bay, Victoriaon 28 June 2001

Mirande

Department of Transport and Regional Services

Australian Transport Safety Bureau

Navigation Act 1912Navigation (Marine Casualty) Regulations

investigation intothe grounding of the Kerguelen Islands (French) registered ship

Mirandein Port Phillip Bay, Victoria

on 28 June 2001

Report No 169

March 2003

ISSN 1447-087XISBN 1 877071 27 7

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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ContentsSummary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Sources of information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

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

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

Mirande . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Pilotage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Pilot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

The incident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

Comment and analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Steering gear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

The pilot and ship’s bridge team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

The chief engineer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

AMSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Submissions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

Mirande . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

Figures1. Mirande . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .iv

2. Portion of chart Aus 143 showing track of Mirande . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

3. Steering gear control panel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

4. Mirande: Events and causal factors chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

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FIGURE 1:Mirande

SummaryOn 27 June 2001, the multi-purpose cargovessel Mirande berthed at Geelong to load acargo of barley. Whilst alongside, an AMSAsurveyor on board for an inspection, formed theopinion that the master and chief engineer wereunder the influence of alcohol and formallyadvised them to cease drinking so that theywould be fit at sailing time.

When the pilot boarded for departure, the ship’schief engineer came to the bridge and whilst notclaiming to be the master, he did not deny itwhen addressed as ‘captain’.

During the outward passage, as the ship passedto the south of beacon 12 in the South Channel,the ship’s steering gear suffered a telemotorsystem failure. None of the bridge team,however, attempted to change to the othersystem or attempted to use the non-follow-up(NFU) steering controls. The ship’s momentumand the proximity of the edge of the channel,however, resulted in the ship grounding within afew minutes.

After the grounding, the pilot asked for themaster to return to the bridge but to no avail.Eventually the pilot was told that the master was‘drunk’. The water police were called andarrived on board at 0020 on 29 June 2001.They performed preliminary breath tests on thepilot and the first, second and third mates. Theresults of all these tests were negative. Thepolice officer then went below and tested the

master and chief engineer. The master’s alcoholreading was 0.29 g/100 ml and that of the chiefengineer was 0.13 g/100 ml.

The report conclusions include:

• Two fuses in the primary side of thetransformer supplying power to the porttelemotor system blew, causing failure of thehand steering in use at the time.

• The mate and third mate had inadequateknowledge of the bridge equipment, partic-ularly the emergency steering change-overprocedures.

• The helmsman had received no training inemergency steering procedures.

• Intoxication of the master resulted in hisabsence from the bridge at the time of thesteering failure and hence in a lack of properleadership, experience and knowledge at atime when it was particularly needed.

The report makes recommendations to:

• The Australian Maritime Safety Authorityshould seek legislation to allow suitablytrained AMSA marine surveyors, where thereare reasonable grounds to do so, to measureblood alcohol levels of ship’s crews usingbreath analysis equipment. A positive test ofa master or key operational crew shouldprovide grounds for detaining the vessel.AMSA should also advise the relevantharbour master or marine authority of thesituation.

• Ship’s officers should ensure that they (andany appropriate seamen) are familiar with theemergency operation of all ship’s equipment.

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Sources ofInformationOfficers and crew of Mirande

The Port Phillip pilot

Australian Federal Police

Victoria Police Service

Electrotech Pty.Ltd

Victorian Channels Authority

Acknowledgements

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

© Commonwealth of Australia 13 October 2000. Allrights reserved.

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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Narrative

MirandeMirande is a five-hold general-purpose cargoship. It can carry general cargo, bulk cargo orcontainers in various combinations. There arefive 30 tonne cranes on board which serve thehatches when loading or discharging. The shipwas built by the Dalian Shipyard in China andwas delivered to the present owners in March1998. It is in class with Bureau Veritas.

The vessel has a length overall of 181.00 m, abeam of 26.00 m, a depth of 14.4 m and asummer draft of 10.02 m. Its gross tonnage(GT) is 18 597, net tonnage (NT) is 9 789 anddeadweight is 29 538 tonnes. It has a containercapacity of 1 172 twenty-foot equivalent units(TEU). The ship is powered by a single B&W5S50MC slow speed diesel engine delivering 5 998kW to a single fixed-pitch propeller. Thevessel’s complement consists of five French andthirteen Indian nationals. The master, mate,second mate and chief engineer were Frenchnationals.

PilotagePort Phillip in Victoria is the site of two ports,the port of Melbourne and the port of Geelong.The Victorian Channels Authority is responsible,under the Port Services Act 1995, for themanagement of port waters for both ports. PortPhillip Sea Pilots is the pilot service providerfor both ports.

Sailing from Geelong, ships negotiate a channelof about 16 miles in length before reachingopen water. The channel consists of four legs,Corio Channel, Hopetoun Channel, Wilson SpitChannel and Point Richards Channel. The Portof Geelong and its channels have a collectiveminimum depth of 12.3 m.

After clearing Point Richards Channel, shipshave a run of about 21 miles in open water, withdepths from 15 m to 24 m, to Hovell Pile.Hovell Pile marks the entrance to SouthChannel from where there is a run of just over13 miles to clear Port Phillip entrance, known asthe Rip. South Channel has a maintainedminimum depth of 13.1 m.

A pilot is said to have the ‘conduct of the ship’although he does not belong to the ship’s crew.He is not in command of the ship but he/she isthere to manage the navigation of the ship,while at all times the master remains incommand. The pilot provides ship handlingskills and knowledge of local conditions. Themaster remains responsible for the safenavigation, the proper conduct of the crew andthe efficient operation of the engine(s) and allother equipment.

Section 410B of the Navigation Act 1912provides:

A pilot who has conduct of a ship is subject tothe authority of the master of the ship and themaster is not relieved from responsibility for theconduct and navigation of the ship by reason onlyof the ship being under pilotage.

The pilotThe pilot assigned the pilotage for Mirande thatevening had about 25 years seagoing experiencein a variety of ship types. He held a Class 1Masters certificate and had been a licenced pilot(restricted) for about one year.

When the pilot arrived at the berth at about1730 and checked the draught he immediatelyrealised that his licence did not qualify him toconduct the pilotage for Mirande, given itsmaximum draught of 10.05 m. He contacted themanaging director of Port Phillip Sea Pilotshimself a very experienced senior pilot, forinstructions.

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The managing director gave the pilot a verbaldispensation to pilot the vessel that evening.This dispensation was given under a long-standing, but unwritten, arrangement betweenthe Pilot Service and the Marine Board ofVictoria, whereby, under special circumstances,the managing director was empowered toprovide such a temporary dispensation.

The managing director knew that it would takeat least two hours to provide a substitute pilot.He was under the impression that any delay toMirande would delay an incoming tanker whichhad a limited tidal window and for which tugshad been ordered.

The incidentOn 08 June 2001, Mirande arrived at Port Pirie,its first Australian port of call, after a voyagefrom Singapore. At Port Pirie the ship loadedtwo holds (Nos. one and four) with 11 228 tonnes of zinc concentrate before sailing,on 11 June 2001, to Geelong anchorage to awaitthe final part of its cargo. A cargo of barley wasto be loaded in the other three, empty, holds.When the ship arrived at the Geelong anchorageon 13 June 2001, the master and some crewundertook a routine crew change.

The ship had not participated in the AusRepsystem, which it is required to do, neither onarrival in Australian waters nor between PortPirie and Geelong.

On 27 June 2001, the ship berthed at No.3 bulkgrain berth and loaded the barley cargo in holdstwo, three and five. The loading of 17 164 tonnes of cargo was completed at 1525on 28 June 2001. During the time in port,AMSA conducted a Port State Controlinspection. On 28 June 2001, at about 1200, anAMSA surveyor returned to the ship to checkon the progress of rectification of a number ofdeficiencies. He formed the opinion that themaster and chief engineer were under theinfluence of alcohol and advised them to ceasedrinking so that they would be fit at sailing

time. The master acknowledged this advice andagreed to stop drinking forthwith.

At 1700, the second and third mates, togetherwith the deck cadet, tested the bridge equipmentin preparation for departure. Sailing wasscheduled for 1800. At 1730, near tocompletion of the tests, the deck cadet wentdown to the main deck to meet the pilot whomhe had seen arriving at the wharf.

When the cadet arrived on the main deck he sawthe pilot on the wharf. The pilot was standing onthe wharf talking with the agent and berthingsuperintendent and making some calls on hismobile phone. The pilot had previously beenadvised by the Geelong Harbour Control thatthe departure draught would be 9.5 m, but onarrival the pilot read the drafts and found themaximum draught to be 10.05 m. The pilot waslicensed to take vessels with a maximumdraught of only 9.5 m so sought advice from themanagement of the pilotage company. He wasgranted permission to undertake this pilotage.At 1755, the pilot and cadet went from thewharf directly to the bridge in preparation forsailing.

The mate was on the bridge together with thethird mate and a seaman/helmsman. Accordingto the ship’s staff, the master was sittingunobtrusively at the after end of the chart roomarea and did not identify himself to the pilot.The third mate then went aft for departurestations. The pilot had not met the master andasked to meet him for the routine informationexchange prior to sailing. The ship’s chiefengineer, however, came to the bridge dressed infull blue uniform and, whilst not claiming to bethe master, did not deny it when addressed as‘captain’. With the mate standing between thepilot and the chief engineer, the pilot explainedhis plan for sailing and the passage through PortPhillip Bay to the pilot disembarkation point.

At 1816 on 28 June 2001, the ship let go andproceeded to sea. Both steering motors wereoperating and the port system was engaged.

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5

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143

show

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Shortly afterwards, the master went below to hiscabin and did not return again to the bridge. Thechief engineer remained on the bridge until thevessel passed Point Henry, then went back downto the master’s cabin where they continued todrink together. The chief engineer returnedfrequently to the bridge for short intervals,apparently to monitor the ship’s progress and totry and cover for the master’s absence. Whenaddressed as ‘captain’ by the pilot on severaloccasions during this time, the chief engineerdid not correct the pilot on the matter of hisidentity.

The departure pilotage from Geelong and acrossPort Phillip proceeded without problem and, atabout 2115, the ship rounded the Hovell Pileand commenced its passage through the SouthChannel to sea. The ship was, at this time, onfull sea speed at about 12.8 knots with the helmon ‘hand’ steering. As the ship passed to thesouth of beacon 12, the ship’s steering gearsuffered a telemotor system failure and thealarm started ringing. The port steering systemhad failed.

The ship began to veer slowly to starboard. Themate tried to cancel the alarm while the thirdmate rang the engine room. None of the bridgeteam attempted either to change to the starboardtelemotor system or to use the non-follow-up(NFU) steering controls.

Shortly afterwards, at about 2135 it wasconfirmed to the pilot that there was a steeringfailure and, as the ship continued sheeringtoward the northern side of the channel, herequested ‘full astern’. The ship’s momentum,however, and the proximity of the shallows nearthe channel edge meant the ship was very soonaground. The grounding, according to the pilot,occurred at 2137.

The pilot asked the chief officer to call thecaptain (the chief engineer) to return to thebridge but was told that he was busy. He

insisted that the captain should come to thebridge, but was again told that he was busy. Thethird mate intervened and said to the mate thatif the pilot wanted to see the captain, he mustget him. By this time, the pilot was becomingextremely suspicious about the master’s absence.

The pilot ran the engine astern for ten to fifteenminutes in an attempt to free the vessel and,being unsuccessful, contacted harbour control toadvise them of the situation and also to requestthe assistance of a representative of the pilotagecompany. The company sent a senior pilot to theship and also called for the attendance of theWater Police.

The pilot, who did not want to leave the bridge,made numerous further requests for the captainto come to the bridge and was repeatedly toldthat he was with the chief engineer. At 2340, heasked the third mate if he, personally, would getthe captain. At this point he was told that ‘thecaptain is drunk’.

When, at 2352, the senior pilot arrived on boardand was unable to contact the master, he wentbelow to the master’s cabin where he found themaster slumped on the deck. The Water Policearrived on board at 0020 on 29 June 2001 andperformed preliminary breath tests on the pilotand the first and third mates. The results ofthese were all negative. The police officer thenwent below and tested the master and chiefengineer. The ship’s pilot also went below andwas surprised when told that the man on thedeck before him was the master. The master’sbreathalyser reading was 0.29 gm/100 ml andthat of the chief engineer was 0.13 gm/100 ml.

After the master, who was unable even to kneelwithout assistance, struck his head on the deckand started bleeding, the water police made acall for medical assistance. At about 0210,paramedics arrived on board by helicopter. Themaster, however, refused to be taken ashore bythe paramedics.

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At 2205 on 29 June 2001, the ship was refloatedby salvors with the assistance of three tugs andanchored off Williamstown while divers checkedfor damage. The master and chief engineer,aboard at the time of the grounding, wererelieved by the owners and, after a new masterand chief engineer joined the ship, AMSAreleased Mirande to continue its voyage to Ma Ta Phut in Thailand.

The master later appeared in the MelbourneMagistrates’ court charged, under section 386Aof the Navigation Act, with being drunk onboard the vessel and being unable to carry outhis duties as master. He was also charged, undersection 386A of the Navigation Act, with havingfailed to furnish a sailing plan in the prescribedmanner after taking a ship to sea. He wasconvicted and fined on both counts.

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Comment andanalysis

EvidenceInterviews were conducted with the mate, thirdmate, the deck cadet, the helmsman, and thechief engineer of Mirande. The master was in anunfit state to be interviewed, even two days afterthe grounding. The pilot who was aboard at thetime of the grounding was later alsointerviewed.

A technician from Electrotech, the Australianagents for Litton Marine Systems, whomanufacture Sperry Marine equipment, wascalled to inspect the Sperry autopilot toascertain the source of the failure, while anelectrician was also engaged to examine theelectrical supplies feeding the steering gearsystems.

The course recorder was in operation. It was notaligned to the correct time so the offset wasnoted and, when checked against the compass, itwas also established that the heading was sixdegrees low.

Steering gearMirande is fitted with a Porsgrunn S1230 rotaryvane steering system driving a single rudder.The steering gear is controlled by a Sperry typeADG 3000 VT Adaptive Digital Gyropilot unitfitted in the wheelhouse. This equipment is onlythree years old and is a high specification unit.The bridge steering pedestal (see fig 3) haseasily accessible and well-marked controls bothfor NFU control as well as for changing oversystems and modes of operation.

The steering motor control panel is immediatelyto the right of the steering pedestal and contains

the start buttons, as well as alarms, lights andbuzzers, for these pumps and motors.

This steering control console is supplied by twoindependent power supplies:

1. a 450/110 volt transformer from the portsteering gear pump starter located on the portside of the steering flat.

2. a 450/110 volt transformer from thestarboard steering pump starter located onthe starboard side of the steering flat.

Both 450/110 volt power supplies are live at alltimes irrespective of whether the pump motorsare running or not.

The primary side of each of these 450/110 volttransformers is fitted with two 2-amp fuses.

All this equipment was fully functional until thetime of the incident. There was no record orrecall of any alarms having been initiated fromthis unit since the ship entered service. Therehad been some problems earlier with an alarmon the hydraulic pumps but this problem hadbeen rectified some months before the incident.

The examination of the Sperry Gyropilot unitand its electrical supplies, which are fed to thewheelhouse from the steering flat, revealed thatthe two 2-amp fuses, fitted at the primary sideof the 450/110 volt transformer in the porttelemotor system, had blown, causing the failureof the steering at the time of the incident.

The tests and checks carried out includedmeasurement of the transformer temperatures ofboth systems (both found to be 47–48°C),measurement of the current drawn by theprimary side of the transformer on each system,and measurement of the surge current drawn at‘switch on’. These parameters were also thesame for both port and starboard systems.

At the end of the tests, the attending Sperryengineer and the electrician had found no

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apparent reason for the fuses to have blown.They did, however, identify that these fusesshould have been of the ‘slow blow’ type andnot of the ‘instantaneous’ type which had, atsome time, been fitted.

Litton Marine Systems did not comment on thefitting of ‘fast blow’ fuses, but did however say:

‘the primary of the transformer should not befused. The US Coast Guard requires that thesecondary should have a disconnect switch andthe secondary should be fused with anywherebetween a 10 and 30 amp fuse after thedisconnect. That is what our drawing shows forthe Mirande. The fuses are there to protect thesteering flat equipment in case remote steeringshorts out. The regulation is there to prevent anautopilot system malfunction from taking out thecomplete steering system. Mind you thisregulation only applies to ships that come underUS Coast Guard rules and does not cover otherregulatory bodies’.

The drawings issued by Porsgrunn SteeringGear A/S, the manufacturers of the rotary-vanesteering gear, however, show the fuses fitted onthe primary side of the transformers. TheInspector finds it difficult to see how fusesfitted in the secondary side of the transformerwould provide protection for the power suppliesto the steering flat equipment in the case of atransformer failure. For this reason it iscustomary to fit the fuses on the primary side ofthe transformer. The remote steering unit (on thesecondary side of the transformer) is also fittedwith fuses.

There was no record of these fuses being fittedat any time after the initial installation of thesteering gear and visual examination indicatedthat they were probably fitted as part of thevessel’s original outfit.

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FIGURE 3:Steering motor control panel

Mode of operationselection switch

NFU operationlever

System select switch

According to the Porsgrunn drawings, the fusesin the supply to the primary side of thetransformers for the autopilot are fitted at theinterface between the equipment supplied byPorsgrunn and that supplied by Litton MarineSystems.

If, indeed, the drawings held by Litton Marineshow the fuses fitted in the secondary side, thenit would appear that the discrepancies betweenthe drawings held by Litton Marine Systems andPorsgrunn Steering Gear A/S and the DalienShipyard were not detected at the time that thesystems were installed during the building.

The pilot and ship’s bridge teamThe pilotage company did not provide anywritten instructions in their procedure manualsto cover the situation confronting the pilot whenhe arrived at the wharf. This pilot was aware ofthe commercial pressure upon him in thissituation but had no procedures to guide hissubsequent actions. He was left with the onlyoption of calling his superiors for instructions.

After the pilot boarded the vessel he did not seethe ship’s master. He believed that the chiefengineer, who was conducting a ‘passive’impersonation of the master, was the master.With the mate standing between him and thechief engineer during the routine pilot/bridgeteam exchange of information before thepilotage, he had little reason to believeotherwise.

The pilotage proceeded routinely and the mate,third mate and helmsman seemed attentive andefficient. However, the pilot was not told thatthe steering had failed until he asked. His firstindication that something was wrong was when,after giving an order to alter about two degreesto port, he heard a high pitched sound from thearea of the steering console and noticed themate, third mate and helmsman close togetherlooking at the steering console. Initially he wasnot unduly concerned. The ship was on a steadycourse and there was six miles of clear water

ahead. Almost immediately, however, the shiptook a sheer to starboard. Initially the shipturned at a rate of 22°/min for just under threeminutes slowing to about 12°/min for twominutes before slowing again to 5°/min. Thecourse recorder indicates that, in all, betweenthe start of the sheer to becoming hard-a-ground, 6 minutes elapsed. This is considerablylonger than the time indicated by the pilot, butthere is some uncertainty about the time atwhich the steering actually failed, the time atwhich the failure was confirmed to the pilot(who was initially not unduly concerned) andthe time at which he might have made his notes.

The grounding should have been avoided. Theship’s staff had three alternative actions to take,each of which would have restored steering.The NFU lever was just to the right hand sideof, and next to, the steering wheel. Justoperating this lever would have overridden thesteering wheel and operated the rudder. Also atthe top left of the control panel was a modeselection switch. Had this switch been turned toNFU, the NFU steering lever would havemaintained steering in the non-follow-up mode.Finally, the telemotor control selection switchwas switched to the port telemotor control. Byturning the switch to the starboard telemotorcontrol, full steering would have been restored.

The master did not contribute in any direct wayto the grounding. His absence from the bridge,however, removed a layer of experience andknowledge, which was absent in the mate andthird mate. The master has overall responsibilityfor the ship and, while the pilot had the conductof the ship for the pilotage passage, the masterremained responsible for the efficient operationof the ship and its equipment.

The mate had limited qualifications though hecarried a dispensation to sail as mate. The factthat he, as senior officer on the bridge, eitherdid not know or did not understand the NFUsystem, calls into question the validity of thedispensation. During the investigation, when

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operating the course recorder, he showed acomplete lack of understanding or compre-hension of that equipment also.

The third mate had recently qualified afterattending the Australian Maritime College.Although having limited experience as awatchkeeping officer, he should haveunderstood, and been able to operate, thesteering equipment in emergency as well asnormal operating modes. The third mate’sreaction was to telephone the engine room.During the investigation, when asked why hedid this, he stated that there had been steeringproblems on previous occasions - an assertionthat the chief engineer at interview denied.There had, some time ago, been alarms relatingto the pumps but not to the control systemswhich activate a different alarm light andbuzzer.

It is clear that neither the mate, third mate norhelmsman understood the operation of thesteering console. The helmsman had never beeninstructed in reverting to emergency steeringalthough the pilot reported that he had steeredproperly and responded to his helm orderspromptly.

The chief engineerThe chief engineer did not correct the pilot atany time when referring to him as ‘captain’,either when the vessel sailed, or during any ofthe subsequent, brief, visits he made to thebridge. It is apparent however that, whilst hedidn’t actually say that he was the master, heplayed the role, deliberately setting out todeceive the pilot into believing that he was themaster. This he later admitted in an interviewwith the Victoria police.

AMSAThe AMSA surveyor was aware of a potentialproblem on the ship at about midday.

He spoke with the master about the situationand received assurances that the master wouldcease drinking and therefore, in the opinion ofthe surveyor, he would have been sober at thetime of departure. AMSA do not haveprocedures detailing the actions to be taken inthese circumstances for the guidance of itsofficers.

No other authorities or organisations wereadvised of this situation by AMSA and nofollow-up actions, after the verbal advice givenby the surveyor, were taken.

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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, the followingfactors are considered to have contributed to thegrounding:

1. For a reason which could not be determined,two fuses in the primary side of thetransformer supplying power to the porttelemotor system blew, causing failure of thehand steering in use at the time.

2. Fuses of the ‘instantaneous’ rather than the‘slow blow’ type had been fitted.

3. The mate and third mate had inadequateknowledge of the bridge equipment, partic-ularly the emergency steering change-overprocedures.

4. The helmsman had received no training inemergency steering procedures.

Additionally but not directly:

5. Intoxication of the master resulted in hisabsence from the bridge at the time of thesteering failure and hence in a lack of properleadership, experience and knowledge at atime when it was particularly needed.

6. The pilot was licensed only to 9.5 mmaximum draught, however the draught was10.05 m and he had obtained a verbalexemption from his managing director toundertake this passage. He had been advisedthat the sailing draught would be 9.5 m bythe ship’s agent.

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FIGURE 4:Mirande: Events and causal factors chart

Even

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Inci

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MR20030012The Australian Maritime Safety Authorityshould seek legislation to allow suitably trainedAMSA marine surveyors, where there arereasonable grounds to do so, to measure bloodalcohol levels of ship’s crews using breathanalysis equipment. A positive test of a masteror key operational crew member should providegrounds for detaining the vessel. AMSA shouldalso advise the relevant harbour master ormarine authority of the situation.

MR20030013The Marine Board and any pilot provider shouldformalise the circumstances under whichexemptions from the limitations placed on apilot’s certificate may be granted. The grantingof such exemptions should be reviewed by theMarine Board to monitor the frequency at whichthis occurs.

MR20030014Port Phillip Sea Pilots Pty Ltd should providewritten procedures to pilots operating withlimited pilotage certificates and should maintaina record of all exemptions granted.

MR20030015Ship’s agents should ensure that the informationprovided to port operations centres and pilotageservices are accurate, particularly that relating tothe ship’s dimensions and draught. If in doubtabout the order of accuracy for requestedinformation or the reason that the information isrequired, agents should seek clarification.

MR20030016Ship’s officers should ensure that they (and anyappropriate seamen) are familiar with theemergency operation of all ship’s equipment.

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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 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 Australian Maritime Safety Authority;

The master, chief engineer, and owners ofMirande;

The Port Phillip Sea Pilots Pty. Ltd.;

The pilot;

The Marine Board of Victoria;

Harbour Master, Victorian Channels Authority.

Submissions were received from:

Marine Safety Victoria (formerly Marine Boardof Victoria);

Harbour Master, Victorian Channels Authority;

The pilot;

The owners of Mirande;

The first mate of Mirande.

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MirandeIMO Number 9149689

Flag Kerguelen Islands

Port of Registry Port-aux-Francais

Classification Society Bureau Veritas

Ship Type Multi-Purpose Ship

Builder Dalian Shipyard, China

Year Built 1998

Owner Transmer SPM

Ship Managers Dockendale Shipping Co Ltd, Bahamas

Gross Tonnage 18 597

Net Tonnage 9 789

Deadweight 29 538 tonnes

Summer draught 10.02 m

Length overall 181 m

Breadth 26 m

Moulded depth 14.40 m

Engine 1 x B&W 5S50MC 5 cylinder, single acting, direct reversing, slowspeed diesel engine

Total power 5 998 kW

Crew 18

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72 Independent investigation into the grounding of the Kerguelen Islands (French) registeredM

irande in Port Phillip Bay, Victoria on 28 June 2001

ISSN 1447-087XISBN1 877071 27 7

Mirande. 02 .2003