Pasha Bulker 243 - Independent investigation into the grounding of ...

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2 ANALYSIS 2.1 Evidence From 9 to 12 June 2007, two investigators from the Australian Transport Safety Bureau (ATSB) collected relevant evidence. The investigators attended the grounded Pasha Bulker and the offices of the legal representative of the ship’s owners. The master, all three mates, helmsman and chief engineer were interviewed and provided their accounts of the incident. The data card from the ship’s voyage data recorder (VDR) was obtained. Copies of log books, bell book, the engine movement logger, weather reports, ship’s certificates, plans, stability information and other relevant documents were also collected. At Newcastle Port Corporation (NPC), the harbour master was interviewed. At Newcastle Vessel Traffic Information Centre (VTIC), the three involved VTIC officers were interviewed. Copies of radar and weather monitoring records, events log, procedures and documents from the centre were also taken. On 18 June, whilst Sea Confidence was berthed in Newcastle, the investigators interviewed the ship’s master. On 8 July, the master of Betis was also interviewed by the investigators after the ship had berthed in Newcastle. On 23-24 August, the investigators obtained further relevant information through meetings and interviews with Port Waratah Coal Services (PWCS) staff, ships agents in Newcastle, NPC and its pilots. During the course of the investigation, information was also obtained from several other sources including Svitzer Salvage. Salvage operations to refloat Pasha Bulker were also attended by the ATSB. During the investigation, the ATSB conducted a survey of the masters of ships in the Newcastle anchorage at the time of the incident. The results of the survey are included in the report (Appendix E). On 19 December, at a meeting with ATSB investigators, further information was provided by NPC and PWCS staff. 2.2 Decisions made on board Pasha Bulker The grounding of Pasha Bulker occurred in extreme weather conditions. However, there were a number of decisions that were made on board the ship from 7 June onwards which, in the circumstances and the weather, contributed significantly to its grounding. 2.2.1 At anchor When the ship arrived off Newcastle on 23 May, Pasha Bulker’s master anchored the ship in a position consistent with the standard anchoring advice from VTIC. At the time, the weather was good, the ship’s distance from the shore was more than - 25 -
the recommended minimum and there was sufficient swinging room. The master did, therefore, consider some of the appropriate relevant factors when anchoring. The passage plan for the voyage to Newcastle had been prepared by the second mate in the form prescribed by the ship’s safety management system (SMS). The passage plan form required the necessary charts and publications to be listed. While the charts were listed, the Australia Pilot and other publications were not. The port information section in the plan provided general information about Newcastle but did not include any reference to the local weather. The master had not signed his approval of the plan and the chief mate had not acknowledged reading it. The master had consulted the chart and stated at interview that the anchorage was ‘good’ with ‘good holding ground’. He appears not to have sufficiently considered the risks due to the weather exposed location of the anchorage which is readily apparent from the chart. Neither was he aware of the guidance provided in the Australia Pilot or other publications on board the ship with regard to the Newcastle anchorage and the local weather. On the morning of 7 June, the master noted the weather forecast and gale warning but apparently did not note the caveat in the forecast which stated that wind gusts could be 40 per cent stronger than the average wind speed forecast and that maximum waves could be twice as high as forecast. However, as a precaution, he veered additional anchor cable and confirmed that the main engine could be used at short notice. He also rested by sleeping for an hour each in the afternoon and the evening in anticipation of being awake during the night to monitor the weather. The master believed that because Pasha Bulker was new, the anchor’s holding power was particularly good and with 11 shackles of cable deployed, the anchor would hold in winds of up to 50 knots. Having not noted the caveat in the weather report, the forecast maximum wind was, according to him, only 45 knots. It is possible that the master’s reference to the ship’s anchor being ‘new’ related to its type, i.e. an Admiralty Class (AC) 14 anchor, a high holding power (HHP 19 ) anchor, as opposed to a standard stockless anchor. The ship’s SMS required the master to specify limits with regard to, amongst other items, the wind, yawing and the ship’s position and an anchor watch checklist to be completed by the mates. There were a number of errors in the checklists completed on 7-8 June, indicating that some items were not understood by either the master or the mates. However, the master had supplemented his instructions to the mates in his night order book. The master stated, at interview, that he believed it was ‘best’ to remain at anchor. The ship’s SMS did not provide him with any specific guidance with regard to safely putting to sea in adverse weather or general guidance about the risks at a weather exposed anchorage. The master was concerned about putting to sea because it might be difficult to manoeuvre in heavy weather. However, he did not consider taking additional ballast in number four cargo hold for the heavy weather that was forecast or filling the ship’s fore and aft peak tanks. He believed that it was safer to remain at anchor and monitor the weather and the ship’s position. He had no plan to depart the anchorage at any particular time or if the wind reached a particular speed. He had made an early decision to take no further action unless he was compelled to or in case the 19 An anchor defined as having a holding power at least twice that of an ordinary stockless anchor of the same weight. - 26 -
Page 2 and 3: ATSB TRANSPORT SAFETY INVESTIGATION
Page 4 and 5: CONTENTS DOCUMENT RETRIEVAL INFORMA
Page 6 and 7: DOCUMENT RETRIEVAL INFORMATION Repo
Page 8 and 9: THE AUSTRALIAN TRANSPORT SAFETY BUR
Page 10 and 11: TERMINOLOGY USED IN THIS REPORT Occ
Page 12 and 13: EXECUTIVE SUMMARY At 0742 1 on 23 M
Page 14 and 15: A number of masters had deployed in
Page 16 and 17: 1 FACTUAL INFORMATION 1.1 Pasha Bul
Page 18 and 19: een to Newcastle many times. The th
Page 20 and 21: Figure 3: Section of navigational c
Page 22 and 23: particular, with their extended fet
Page 24 and 25: At 0742, Pasha Bulker’s starboard
Page 26 and 27: oarding ground for its scheduled be
Page 28 and 29: By 0600, only 27 ships remained and
Page 30 and 31: Figure 6: Section of VTIC radar scr
Page 32 and 33: Figure 8: Section of navigational c
Page 34 and 35: mates suggested to the master that
Page 36 and 37: Figure 10: An aerial view of Pasha
Page 38 and 39: Figure 11: A visualisation of Pasha
Page 42 and 43: anchor dragged. The decision was ba
Page 44 and 45: enough and ascertain the effect of
Page 46 and 47: No one on the bridge, at any time,
Page 48 and 49: 2.2.3 The critical decisions A numb
Page 50 and 51: severe weather at the time, it is l
Page 52 and 53: While a number of masters probably
Page 54 and 55: and continued for about 12 hours wi
Page 56 and 57: the angle increases, the holding po
Page 58 and 59: For a bulk carrier, the tension in
Page 60 and 61: It is good practice for bulk carrie
Page 62 and 63: Along with its safety functions, NP
Page 64 and 65: decided to remain anchored in adver
Page 66 and 67: ‘afraid’ because the ‘wind wa
Page 68 and 69: In early 2004, when the ship queue
Page 70 and 71: While the coal producers pay demurr
Page 72 and 73: 3 FINDINGS 3.1 Context On 23 May 20
Page 74 and 75: minimum considered to be acceptable
Page 76 and 77: 4 SAFETY ACTIONS 4.1 Safety action
Page 78 and 79: assumed, incorrectly, that the appr
Page 80 and 81: MS20080018 A number of masters at N
Page 82 and 83: APPENDIX A: EVENTS AND CONDITIONS -
Page 84 and 85: APPENDIX B: SHIP INFORMATION Pasha
Page 86 and 87: APPENDIX C: SOURCES AND SUBMISSIONS
Page 88 and 89: Seamanship International Limited, B
Page 90 and 91:
APPENDIX D: METEOROLOGICAL INFORMAT
Page 92 and 93:
Table 4: Swell condition Descriptio
Page 94 and 95:
APPENDIX E: SURVEY INFORMATION AND
Page 96 and 97:
Question 4: When the weather worsen
Page 98 and 99:
Factors considered in deciding to l
Page 100 and 101:
Question 11: Where can you get the
Page 102 and 103:
Comparison 2a One of the 42 masters
Page 104 and 105:
APPENDIX F: MEDIA RELEASE ATSB rele
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