A bulk carrier came within 200 m of grounding in the Great Barrier Reef after a GPS unit onboard the ship began providing false information to the pilot and crew on board, an ATSB final report details.
The near grounding occurred early on the morning of 4 May 2022, when the 225 m bulk carrier Rosco Poplar was transiting Hydrographers Passage under the conduct of a coastal pilot.
Unknown to the pilot and crew, one of the ship’s 3 GPS units began outputting incorrect positional data during the early stages of the pilotage, likely due to an antenna malfunction.
The ship’s position was then incorrectly displayed on the ship’s navigational equipment, including the electronic chart display and information system, radars and automatic identification system.
As the ship came within 200 m of Bond Reef, where normal clearance was about 1,500 m, the pilot suddenly noticed a reef sector light indicating red. This was followed by the activation of an alert from the ship’s electronic navigational equipment.
The pilot ordered a heading change and the ship’s course was altered away from the reef, and the remaining pilotage was conducted without further incident.
The investigation found the pilot and bridge team relied solely on GPS positioning to monitor the ship’s progress, and the pilot failed to correctly configure their portable pilot unit to be independent of the ship’s position sensors.
The ATSB also determined ineffective bridge resource management and ineffective pilotage contributed to the occurrence.
“An inadequate master-pilot information exchange did not establish individual roles and responsibilities for watchkeeping and communication, while the second mate was given tasks which distracted them from their duties for monitoring the passage plan, and maintaining a proper lookout,” ATSB Chief Commissioner Angus Mitchell outlined.
“This occurrence demonstrates the importance of the various concepts, techniques and attitudes that together comprise effective bridge resource management.”
In the course of its investigation the ATSB also identified that the coastal pilotage check pilot system did not provide the intended competency assurance to the Australian Maritime Safety Authority (AMSA).
While this did not contribute to the near-grounding incident, the ATSB identified significant variations in the application of assessment standards between individual check pilots, indicating assessment outcomes were not a valid and reliable indicator of competency.
AMSA has advised that a review of coastal pilotage under the current legislation is underway, however the ATSB has issued AMSA with a safety recommendation to address factors limiting the effectiveness of its check pilot framework as a system for coastal pilot competency assurance.
“Compulsory coastal pilotage remains an essential defence against serious shipping accidents in the Great Barrier Reef,” Mr Mitchell said.
“It is therefore important that coastal pilots are up to standard – and any assessment system that assures those standards must produce consistent and accurate outcomes.
“If sufficient measures are not implemented to ensure assessment standards are interpreted and applied consistently – irrespective of the assessor – the outcomes are unreliable.”
The investigation also identified that the vessel traffic services operator assessed an unusual grounding alert display associated with the Rosco Poplar’s GPS malfunction as erroneous.
“Consequently, the pilot and ship’s crew were not provided with timely advice of the indicated proximity to Bond Reef,” Mr Mitchell concluded.
You can find here the final report:
