case study 1308

The task:

You are to analyse the below described incident, and write a report that

addresses the following issues:

• Identification of safety issues in the incident;

• The safety lessons that can be learned from actions of the ship’s


• Identification of any possible breaches of relevant international

conventions and/or Australian legislation;

• Suggest proactive safety action for involving stakeholders in

response to this incident.

The Case:

The grounding of a Panama-flagged vessel on a shoal off the coast

of Townsville

General particulars of the vessel: an ore carrier with 230 m LOA, breadth

of 33.4 m and a depth of 19.1 m. The ship has a DWT of 74,285 tonnes

and its summer draught of 13.862 m. The ship is equipped with standard

navigation equipment according to SOLAS requirements, including two

GPS units, an AIS system unit and two X-band radars, but no electronic

chart facility was installed.

The crew members are experienced and hold qualifications for their

positions in accordance with international requirements. In particular:

• The master had 26 years of experience with 10 years in the

capacity of master. He joined the ship 5 months before the

incident. The master has visited Australian ports before, but this

was his first visit to Townsville.

• The chief mate had 21 years of experience and had been sailing

as chief mate for 3 years. He had just joined the vessel in the

previous port of departure and like the master, he had never

visited Townsville before.

The mates maintained a traditional watchkeeping routine of 4 hours on

and 8 hours off. The third mate kept the 8 to 12 watch, the second mate

kept the 12 to 4 watch and the chief mate kept the 4 to 8 watch. In port,

the chief mate worked additional hours as required for cargo operations

Events preceding the grounding

Nine days before the incident, the vessel arrived at the anchorage off

the port of Townsville in ballast condition and dropped anchor. While

at anchor, the crew carried out routine maintenance tasks and the

officers carried out usual anchor watch duties.

Four days before the incident, the chief officer started spending about

3 hours after each evening watch checking cargo and stability

calculations and compare the results with the calculation from the

loading computer.

The day before the incident


The ship received instructions from harbor VTS about the estimated

pilot boarding time of 0400.


The crew started prepare to get underway. The chief mate went to the

forecastle to oversee the anchor weighing.


Anchor was aweigh. The ship was under way to the pilot boarding



The chief mate returned to the accommodation and prepare for his



The chief mate took over the watch from the second mate.


Pilot embarked the ship and joined the bridge team consisting of the

master, chief mate, and helmsman. After exchanging information, the

pilot took over the conduct of the ship and guided her to berth.


The crew prepared to make fast the tugs. The third mate take over the

place of the chief mate as he went to the forward station. The second

mate went to command the aft station.


All tugs made fast. The ship was maneuvered toward her berth.


The ship was all fast, starboard alongside her berth. The chief mate

returned to the ship’s office and prepared for receiving cargo.


Loading started. The third mate and the second mate supervised cargo

operation on deck while the chief mate supervised from the ship’s cargo

control room throughout the day, taking meal breaks when he could.

The ship continued with cargo operation.

The day of the incident


The chief mate left the second mate in charge of loading operation and

went to his cabin to sleep.


The cargo surveyor board the ship and the chief mate was called after

as they were about to conduct final stages of the loading operation.


The ship finished loading. Her draughts were 13.68 m forward and 14.05

m aft.


draught survey finished and the chief mate and the cargo surveyor

discussed necessary cargo calculations and paper work. At 0730, the

surveyor passed on final figures to the terminal and other parties

ashore. The chief mate continued verifying cargo figures and ship

stability calculation until 0900 when he left for breakfast, returning 30

minutes later to complete the paperwork.


Pilot on embarked the vessel. The ship was ready for departure. The

master and the third mate were on the bridge, the chief mate and

second mate were standing by at fore and aft stations respectively.


All tugs made fast.


Vessel under way.


All tugs away


Forward and aft stations were stood down. Anchors still standby for



The second mate took over the watch from the third mate. The ship was

navigating with a speed of 10 knots under hand steering. The pilot gave

steering orders while the master kept monitoring the ship.


The chief mate finished lunch and retreat to his cabin to rest, setting

the alarm clock to wake him at 1530 for his watch. He then lied down

on his bed and initially had trouble sleeping but subsequently felt



Pilot away.


The ship’s position was fixed using GPS and plotted on the chart,

indicating that the ship was on the intended course of 000(T). The

master ordered full sea speed and the ship commenced her voyage to

the next port of call. The weather was good: calm sea, wind NE 15 knots,

clear visibility, clear sky. The ship then engaged in auto-pilot.

The master then ordered the second mate to adjust the planned route

by bypassing the next course alternation waypoint (from 000(T) to

075(T)), resulting in a new track of 020(T). The new course would rejoin

the 075(T) track 5 miles further east than planned and reduce the

voyage by about 2 miles. The second mate complied and laid the new

course line on the current chart and the next one. The original course

line on both chart was not erased. The second mate also did not enter

the coordinates of the amended waypoints in the GPS unit, however, he

did write them next the amended track on the chart.

(* The GPS installed on the ship was set to indicate bearing and distance

to the next waypoint, the XTE alarm was set for 3 cables, and the

waypoint arrival alarm was set for 2 cables. The radar automatically

displayed the bearing of the next waypoint, fed from the GPS).


The ship continued en-route with her engine at full sea speed, reaching

12 knots. The master handed the conn to the second mate and left the

bridge. The duty seaman remained on the bridge for lookout duties.


The ship’s position was fixed using GPS and plotted on the chart,

indicating the ship was on the intended course.


The ship arrived at the amended course alternation point. The second

mate marked the time on the chart and altered course to 020(T). Soon

after, the GPS unit triggered cross track error alarm indicating the ship

had moved 3 cables off the original 000 (T) course line. The second mate

acknowledged the alarm and continued keeping watch. The GPS unit

and radar continued to display waypoint and cross track error

information relative to the original track.

At the same time, the chief mate awoke in his cabin and started

preparing for his watch, having slept for about 30 minutes.


The chief mate arrived on the bridge and checked the log book and

chart. The second mate noticed that the chief mate seemed tired and

he started explaining to the chief mate about the changes to the passage

plan and the new track of 020 (T) and showed him the next waypoint.

The second mate noted to the chief mate that the amended waypoint

had not been entered in the GPS unit. The chief mate acknowledged

this fact.


The second mate fixed the ship’s position by GPS, plotted on the chart,

handed over the watch to the chief mate, and left the bridge.

The chief mate assessed the situation and estimated that the ship would

arrived at the next waypoint, for the 075 (T) course alternation, at about

1700. He then decided to fix the ship’s position at 1630 and continued

keep watch with the duty seaman.


The chief engineer came to the bridge and asked for the ship’s speed,

which the chief mate replied 12 knots. The chief engineer left the bridge

at 1635. This interrupted the chief mate from fixing the ship’s position

at 1630, so he decided to fix the ship’s position at 1700.


The vessel crossed the next waypoint, where the ship’s track would have

been turned to 075 (T).


The chief mate fixed the ship’s position using GPS and plotted it on the

chart. He realized that the ship had passed the course alternation

waypoint about 20 minutes ago, deviated significantly from the

amended track and entering the “no go area” of shallow water marked

on the chart. He also noticed that the ship’s speed had decreased to

about 8 knots.

The chief mate immediate ordered the lookout seaman to engage hand

steering and alter course to starboard. However, just as hand steering

mode was engaged, the chief mate saw the ship’s speed rapidly decrease

and the ship began to shudder. The starboard helm had no effect and

soon the ship’s speed was close to zero.

In his cabin, the master felt the ship shudder, but assumed that the ship

was altering course.


The ship had come to a shuddering stop and grounded on a heading of

020 (T).

The chief mate called the master and asked him to come to the bridge.

The master hurried to the bridge, where he was informed by the chief

mate that the ship may have ran aground. The master noticed the ship’s

speed was zero and ordered the chief mate to fix the ship’s position

using GPS. The plotted position on the chart confirmed that the ship

had grounded. The charted depth was 9.8 m and it was almost low tide.


The chief engineer and the second mate arrived on the bridge,

suspecting unusual movement of the ship. The master asked the chief

engineer to stop the main engine and send the chief mate forward to let

go an anchor. He also ordered sounding all tanks and water depths

around the ship.


Starboard anchor was let go with 2 shackles in the water.

The sounding confirmed that the ship’s hull was breached, one double

bottom ballast tank was flooded and there was water ingress into other

port side ballast tanks.

Depth sounding around the ship confirmed that she was hard aground.

The master informed the ship’s manager of the incident.


The master reported the grounding to the Australian Maritime Safety

Authority (AMSA).


AMSA issued notices to shipping and notified relevant parties.


An AMSA casualty coordinator, transported by helicopter, boarded the

ship. No sign of oil leaking was detected visually by the helicopter pilot.

Later on, inspection by the casualty coordinator confirmed pollution

from a breached bunker fuel oil tank. Approximately 3 tonnes of bunker

oil was lost overboard. Oil and water also entered the engine room and

the main engine was disabled.

The ship remained aground through the night.

Initial investigations found:

All the ship’s navigation equipment was in working order.

The ship’s safety management system contains provisions for hours of

work and minimum rest period on board, consistent with the

requirements from the STCW Code. The guidance to comply with the

provisions was as follow: “The master is responsible for managing

working hours of all crew

"Is this question part of your assignment? We can help"