Ineffective Bridge Resource Management Leads to Bulk Carrier Grounding in Western Australia

Ineffective bridge resource management contributed to the grounding of a bulk carrier in the Port of Bunbury, Western Australia, an Australian Transport Safety Bureau (ATSB) investigation has found.

The incident took place on April 22, 2023, when the 229-meter long, Isle of Man-registered bulk carrier World Diana was departing Bunbury with harbor pilot and two tugs assisting. After being moved off its berth, the ship had to be turned in the turning basin before exiting the harbor.

“This turn was started earlier than planned, reducing the amount of room available,” Chief Commissioner Angus Mitchell said. “The ship’s speed was then allowed to increase until there was no room to safely turn, and the bow of the ship grounded on a shallow bank to the east of the harbour entrance.”

The ship sustained minor hull damage but was able to be manoeuvred off the bank, and fortunately, no pollution was reported.

The ATSB’s investigation found bridge resource management during the pilotage was ineffective. “Bridge resource management is an important part of safe pilotage,” Mitchell stated. “Effective use of available resources reduces the chance of single-person errors and minimises their impact.”

The report notes that proper use of the available portable pilot unit, effective communication, and active involvement of the World Diana’s bridge team and the tug masters, would have allowed the deviation from the plan to be detected in time to prevent the grounding. “Specific information and limits for the departure plan were only known to the pilot, which made it difficult for the bridge team to raise concerns during the event,” Mitchell added.

“Nevertheless, had the ship’s master – an experienced ship-handler familiar with the ship’s movement characteristics – been actively monitoring the pilotage, the early turn and ship’s increasing headway should have become evident.”

Additionally, the ATSB found that the Port of Bunbury had not developed adequate procedures for arrival and departure plans for larger ships berthed on their starboard side alongside berth no. 3. “This reduced the information available to pilots for these ship movements, and to share with bridge teams and tug masters to ensure a common understanding of how manoeuvring would be conducted,” Mitchell concluded.

Read the report: Grounding of World Diana on 22 April 2023

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