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ATSB examination: The start of the pilots runs aground after he has misinterpreted his course

ATSB examination: The start of the pilots runs aground after he has misinterpreted his course

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The Australian Transport Safety Bureau (ATSB) has created an investigation report on an incident in which the pilot start of the pilot start Corsar, Call up the pilot from the outgoing MV Rio GrandeRun on Point Lonsdale Reef because of misinterpreting his course.

What happened

OOn the evening of October 5, 2023, the Pilot Start Corsair picked up the pilot from the outgoing container ship MV Rio Grande after leaving Port Phillip. The pilot's transfer took place off the coast, about 4.2 km southwest of Point Lonsdale. Port Phillip Sea Pilots (PPSP) was the pilot provider and operator of the pilot start. The start of the pilot began with about 2307 the return to the entrance of Port Phillip to return to the pilot station in Queenscliff in the bay. Around 2310 and at about 2.3 km southwest of Point Lonsdale, the Coxswain began a slow change in the course at the port of around 18 °. Corsair was about 760 m from the Lonsdale Reef point when it was on a course towards the reef. Corsair was located west of the location intended by Coxswain and then ran on Point Lonsdale Reef with about 2313 to 24 knots.

What the ATSB found

It was found that COXSWAIN from Corsair shines the leading ones, which marked the entry into Port Phillip, incorrectly interpreted and navigated to the west of their intended course through the entrance. The return to Port Phillip according to Offshore pilot transmission was a routine activity that the Coxswain had carried out on many occasions. That night her perception of navigation lights on Shortland Bluff was probably influenced by your expectations of what you would normally observe.

The likelihood of human error can be reduced by the use of protection systems of technology, other occupation resources and the procedure. In this case, the navigation of Corsair through the Coxswain was mainly visually demonstrated by the entrance to the proof of on -board devices in order to confirm the ship's approach. The other launch -crew member, a cover hand, was also not actively involved in the navigation of the ship.

The security management system of a ship offers the structures and guidelines to support a consistent approach to ship processes. It was found that the security management system and the Pilot Start -Safety Management methods with instructions for the start crew can be improved via the operating practices for navigation through the entrance to Port Phillip and the effective use of the devices and cover hand.

It was also found that training material for Start -Coxswains contained only limited details about the criteria for the course content and ratings and training documents were incomplete. There was also no refresher crew training in navigation practices.

Although this is not considered influenced, additional findings for checking potential are carried out by the safe transport of Victoria of local knowledge certification requirements for Masters of domestic merchant ships in Port Phillip Heads.

Contribute to factors
  • The Start Coxswain interpreted incorrect navigational aids that marked the entry into Port Phillip and navigated after the west of secure passage through the entrance. The Coxswain had gone through the heads many times and their perceptions were probably influenced by the expectations of what they would normally observe.
  • The Start Coxswain was based on its visual observations of navigation aids and did not use the available navigation devices in board by the entrance to Port Phillip.
Other factors that increased the risk
  • It was probably not a normal practice for starting deck handles to actively support the start navigation. In addition, the layout of the navigation displays on Corsair did not allow any simple transfer through the cover hand.
  • The security management system for Corsair contained no detailed instructions and reference material for the safe navigation of Port Phillip Heads, the effective use of start navigation devices and the role of starting deck in supporting the safe navigation.
  • The documentation to support the training and competence assessment of Coxswains was limited in detail and the training documents were incomplete.
Other knowledge
  • The navigation devices on Corsair had additional (unused) functions with which navigation through Port Phillip Heads could support the starting system.
  • The regulation did not require local knowledge certification from Masters of non-passenger domestic merchant ships (DCV), which worked in the high risk area of ​​Port Phillip Heads. This differed from the rest of Port Phillip, for whom a local knowledge certification was required for masters of DCV with non-passengers with a length of more than 12 m. There was the possibility for a safe transport of Victoria to check the requirement for Port Phillip Heads.