Port Phillip,Port on4January2006. Victoria oiltanker registered Indian of thegrounding into the investigation Independent ATSB TRANSPORT SAFETY INVESTIGATION REPORT Marine Occurrence Investigation No. 223 Final Independent investigation into the grounding of the Desh Rakshak Indian registered oil tanker Desh Rakshak in the entrance to Port Philip, Victoria intheentrance to 4 January 2006 ATSB TRANSPORT SAFETY INVESTIGATION REPORT Marine Occurrence Investigation No. 223 Final Independent investigation into the grounding of the Indian registered oil tanker Desh Rakshak in the entrance to Port Phillip, Victoria 4 January 2006 Released in accordance with section 25 of the Transport Safety Investigation Act 2003 Published by: Australian Transport Safety Bureau Postal address: PO Box 967, Civic Square ACT 2608 Office location: 15 Mort Street, Canberra City, Australian Capital Territory Telephone: 1800 621 372; from overseas + 61 2 6274 6440 Accident serious incident notification: 1800 011 034 (24 hours) Facsimile: 02 6274 6474; from overseas + 61 2 6274 6474 E-mail: [email protected] Internet: www.atsb.gov.au © Australian Government 2007. This work is copyright. In the interests of enhancing the value of the information contained in this publication you may copy, download, display, print, reproduce and distribute this mate- rial in unaltered form (retaining this notice). However, copyright in the material obtained from non-Commonwealth agencies, private individuals or organisations, belongs to those agencies, individuals or organisations. Where you want to use their material you will need to contact them directly. Subject to the provisions of the Copyright Act 1968, you must not make any other use of the material in this publication unless you have the permission of the Australian Transport Safety Bureau. Please direct requests for further information or authorisation to: Commonwealth Copyright Administration Copyright Law Branch Attorney-General’s Department Robert Garran Offices National Circuit BARTON ACT 2600 www.ag.gov.au/cca ISBN and formal report title: see ‘Document retrieval information’ on page v. ii CONTENTS DOCUMENT RETRIEVAL INFORMATION v THE AUSTRALIAN TRANSPORT SAFETY BUREAU vii TERMINOLOGY USED IN THIS REPORT ix EXECUTIVE SUMMARY xi 1 FACTUAL INFORMATION 1 1.1 Desh Rakshak 1 1.2 Port Phillip 2 1.3 The incident 5 2 ANALYSIS 11 2.1 Evidence 11 2.2 The grounding 11 2.2.1 The rock found in the ship’s lower fore peak tank 11 2.2.2 The ship’s track 12 2.3 Under keel clearance (UKC) 12 2.3.1 Squat 12 2.3.2 Movement in the seaway 14 2.3.3 UKC monitoring 14 2.4 Bridge resource management (BRM) 15 2.5 The pilotage 16 2.5.1 The pilot boarding ground 17 3 FINDINGS 19 3.1 Contributing safety factors 19 3.2 Other key findings 19 4 SAFETY ACTIONS 21 4.1 Safety action by Port of Melbourne Corporation 21 4.2 Safety action by Port Phillip Sea Pilots 21 4.3 ATSB recommendations 21 5 APPENDIX A: EVENTS AND CONDITIONS 23 6 APPENDIX B: SHIP INFORMATION 25 6.1 Desh Rakshak 25 7 APPENDIX C: SOURCES AND SUBMISSIONS 27 7.1 Sources of information 27 7.2 References 27 7.3 Submissions 27 8 APPENDIX D: MEDIA RELEASE 28 iii iv DOCUMENT RETRIEVAL INFORMATION Report No. Publication Date No. of pages ISBN ISSN 223 April 2007 40 978-1-921164-50-7 1447-087X Publication Title Independent investigation into the grounding of the Indian registered oil tanker Desh Rakshak in the entrance to Port Phillip, Victoria on 4 January 2006. Prepared by Reference number Australian Transport Safety Bureau Mar2007/DOTARS 50160 PO Box 967, Civic Square ACT 2608 Australia www.atsb.gov.au Acknowledgements The chart section in this publication is reproduced by permission of The Australian Hydrographic Service. © Commonwealth of Australia 13 October 2002. All rights reserved. Other than for the purposes of copying this publication for public use, the chart information from the chart sections may not be extracted, translated, or reduced to any electronic medium or machine readable form for incorporation into a derived product, in whole or part, without the prior written consent of the Australian Hydrographic Service. The satellite image of Port Phillip was downloaded from the Port Phillip Sea Pilots website. Abstract Desh Rakshak arrived off Port Phillip on the morning of 4 January 2006, with about 80 000 tonnes of crude oil cargo on board, and at 0800 a pilot boarded the ship for the transit from sea to the Melbourne outer anchorage. The pilot planned to enter the port to the west of the track marked by the main leading lights, to keep the ship out of an opposing tidal flow for as long as possible. When the ship was almost abeam of Point Lonsdale Lighthouse, the pilot thought he could see the high and low main leading lights just open to the west. This indicated to him that the ship was on the edge of the Great Ship Channel. However, the ship was further to the west than the pilot thought. The ship continued the transit and anchored at 1154. No one on board the ship observed anything that might have suggested that the ship had grounded during the pilotage. At about 1245, the chief mate found the level in the lower fore peak water ballast tank rising. He told the master, and they decided to pump out the tank and inspect it. The inspection revealed that the tank’s shell plating had been holed. The ship berthed in Geelong on 5 January and temporary repairs were carried out before it sailed for Singapore on 19 January, where it was dry-docked for permanent repairs. The investigation found that the ship probably grounded at about 0825, when it was almost abeam of Point Lonsdale, while transiting from sea to the Melbourne outer anchorage. The report identifies a number of contributing factors and makes recommendations to address them. v vi THE AUSTRALIAN TRANSPORT SAFETY BUREAU The Australian Transport Safety Bureau (ATSB) is an operationally independent multi-modal Bureau within the Australian Government Department of Transport and Regional Services. ATSB investigations are independent of regulatory, operator or other external bodies. The ATSB is responsible for investigating accidents and other transport safety matters involving civil aviation, marine and rail operations in Australia that fall within Commonwealth jurisdiction, as well as participating in overseas investigations involving Australian registered aircraft and ships. A primary concern is the safety of commercial transport, with particular regard to fare-paying passenger operations. The ATSB performs its functions in accordance with the provisions of the Transport Safety Investigation Act 2003 and Regulations and, where applicable, relevant international agreements. Purpose of safety investigations The object of a safety investigation is to enhance safety. To reduce safety-related risk, ATSB investigations determine and communicate the safety factors related to the transport safety matter being investigated. It is not the object of an investigation to determine blame or liability. However, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. Developing safety action Central to the ATSB’s investigation of transport safety matters is the early identification of safety issues in the transport environment. The ATSB prefers to encourage the relevant organisation(s) to proactively initiate safety action rather than release formal recommendations. However, depending on the level of risk associated with a safety issue and the extent of corrective action undertaken by the relevant organisation, a recommendation may be issued either during or at the end of an investigation. The ATSB has decided that when safety recommendations are issued, they will focus on clearly describing the safety issue of concern, rather than providing instructions or opinions on the method of corrective action. As with equivalent overseas organisations, the ATSB has no power to implement its recommendations. It is a matter for the body to which an ATSB recommendation is directed (for example the relevant regulator in consultation with industry) to assess the costs and benefits of any particular means of addressing a safety issue. vii viii TERMINOLOGY USED IN THIS REPORT Occurrence: accident or incident Safety factor: an event or condition that increases safety risk. In other words, it is something that, if it occurred in the future, would increase the likelihood of an occurrence, and/or the severity of the adverse consequences associated with an occurrence. Safety factors include the occurrence events (e.g. engine failure, signal passed at danger, grounding), individual actions (e.g. errors and violations), local conditions, risk controls and organisational influences. Contributing safety factor: a safety factor that, if it had not occurred or existed at the relevant time, then either: the occurrence would probably not have occurred; or the adverse consequences associated with the occurrence would probably not have occurred or have been as serious, or (c) another contributing safety factor would probably not have occurred or existed. Other safety factor: a safety factor identified during an occurrence investigation which did not meet the definition of contributing safety factor but was still considered to be important to communicate in an investigation report. Other key finding: any finding, other than