Shen Neng 1: Fatigue, Inexperience, Wrong Chart

In essence, a simple succession of errors on the part of a very tired crew member resulted in the grounding of Shen Neng 1 on Douglas Shoal, part of the Great Barrier Reef about 50 miles2 north of the entrance to the port of Gladstone, Queensland.

on 3 April 2010 says Australia’s Transport Safety Bureau. ATSB warns that the report, released on 15 April 2010 is only preliminary and further investigations leading to the final report may differ.

Key points are that it was the first mate’s first time navigating through this area; the first mate had had a very busy time while the ship was in Gladstone loading and he had had only 2.5 hours of broken sleep in the previous 37 hours, he was alone on the bridge with one seafarers as lookout; earlier the second mate and master had decided to alter the ship’s planned route slightly and used Chart Aus 819 which did not show Douglas Shoal; the ‘off-track’ or course alteration ‘waypoint’ alarms set in the ship’s Global Positioning System (GPS) receiver unit were not changed. These navigational safeguards remained set for the original course; at 1530 the second mate altered course to the new planned route. Shortly thereafter he received an “off-track” alarm on the GPS and “accepted” this alarm; The first mate took the watch at 1600; when the ship moved into the area covered by chart Aus 820, the first mate did not change the charts on the chart table, nor did he establish the ship’s distance from the  next course alteration point; when the ship reached the course alteration point, the chief engineer visited the ship’s bridge for five minutes or so to check the main engine revs. The first mate had intended to fix the ship’s position at this time but now decided he would do so 30 minutes later.

Says ATSB: “At 1700 the first mate took the ship’s position coordinates from the GPS to plot its position. It was at this stage that he took out chart Aus 820 from the chart drawer. At this time he realised that the ship was past the amended alteration point and was very close to Douglas Shoal.

"He attempted to alter course at the last minute but this action was too late and shortly thereafter the ship grounded at a speed of about 12 knots.”

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