MARINE SAFETY INVESTIGATION

REPORT 182

Independent investigation into the grounding of theGreek registered ship

at Piper Reef, North Queenslandon 29 July 2002

Doric Chariot

A U S T R A L I A N G O V E R N M E N T — D E P A R T M E N T O F T R A N S P O R T A N D R E G I O N A L S E R V I C E S

Department of Transport and Regional Services

Australian Transport Safety Bureau

Navigation Act 1912Navigation (Marine Casualty) Regulations

investigation into the grounding of the Greek registered shipDoric Chariot

at Piper Reef, North Queenslandon 29 July 2002

Report No 182

September 2003

ISSN 1447-087XISBN 1 877071 36 6

Readers are advised that the Australian Transport Safety Bureau investigates for the sole purpose ofenhancing transport safety. Consequently, Bureau reports are confined to matters of safety significanceand may be misleading if used for other purposes.

Investigations commenced on or before 30 June 2003, including the publication of reports as a resultof those investigations, are conducted in accordance with the Navigation (Marine Casualty)Regulations 1990, made pursuant to subsections 425(1)(ea) and 425 (1AAA) of the Navigation Act 1912.

Investigations commenced on or after 1 July 2003, including the publication of reports as a result ofthose investigations, are authorised by the Executive Director of the Bureau in accordance with theTransport Safety Investigation Act 2003 (TSI Act). Reports released under the TSI Act are notadmissible as evidence in any civil or criminal proceedings.

It is ATSB policy to publish such reports in full as an educational tool to increase awareness of thecauses of marine incident reports so as to improve safety at sea and enhance the protection of themarine environment,

To increase the value of the safety material presented in this report, readers are encouraged to copy orreprint the material, in part or in whole, for further distribution, but should acknowledge the source.Additional copies of the report can be downloaded from the Bureau’s website www.atsb.gov.au

Australian Transport Safety BureauPO Box 967Civic Square ACT 2608 AUSTRALIA

Phone: 02 6274 64781800 621 372

Fax: 02 6274 6699E-mail: marine@atsb.gov.au

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CONTENTS

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Sources of Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Acknowledgment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Narrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Doric Chariot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Great Barrier Reef compulsory pilotage area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Pilotage services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

The incident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Comment and analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

The master . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Actions of the OOW – 0235 to 0335 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

Actions of the pilot – 0235 to 0335 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

Alertness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

The pilot’s work schedule and level of alertness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

The 'best' case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

The 'worst' case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

Bridge resource management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

Previous accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

Safety actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

Drugs and alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

Submissions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25

Doric Chariot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

Figures

1. Doric Chariot aground on Piper Reef . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vi

2. Photograph across the chart table towards the daybed on the port side . . . . . . . . . . . . . . . . . . . .vi

3. Portion of chart Aus 835 showing grounding position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

4. Photograph taken from starboard bridgewing of Doric Chariot with Piper Reef light beacon

in the background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

5. Aerial photograph of Doric Chariot aground on Piper Reef . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

6. Sleep credit/deficit analysis graph . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

7. The 'best' case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

8. The 'worst' case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

9. Doric Chariot: Events and causal factor chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22

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v

vi

FIGURE 1:Doric Chariot aground on Piper Reef

FIGURE 2:Photograph across the chart table towards the daybed on the port side

Pilot's daybed

Summary

On 26 July 2002 Doric Chariot sailed from HayPoint, Queensland on a voyage to India via theGreat Barrier Reef inner passage and Singapore.A pilot was engaged for the Reef passage.

The voyage initially proceeded normally and, on29 July, as the ship approached Eel Reef light,the pilot requested a slight course alteration toallow more sea room for passing a south-boundship. After passing this ship the pilot requestedanother course adjustment to bring the ship backtoward the planned track. He then spoke withthe OOW (Officer of the Watch) about the timehe should next be called and sat on the daybedat the side of the wheelhouse to take a restbefore the ship arrived at the next reportingposition near Piper Reef.

The ship continued under the direction of theOOW until the pilot was next called. When thepilot stood up and looked at the ship’s positionwith reference to the two beacons ahead at Piperand Inset Reefs, he immediately realised that theship was to the west of the two-way route andapproaching the southern end of Piper Reef. Heordered, ‘hard-a-starboard’ and, shortlyafterwards ‘full astern’ but it was too late. Theship started to swing to starboard but, withinabout one and a half minutes, at about 0335, theship ran aground to the south of Piper Reeflight.

The ship was successfully refloated on 6 August2002. No injuries or pollution resulted from thegrounding.

The report concludes that the pilot:

1. sat down intending to rest but fell asleep, inan inappropriate area of the pilotage passage;

2. instructed that he should next be called in aposition too close to the approaching dangersfor any successful corrective action to betaken should it be required;

3. was likely to have been experiencing asignificant level of fatigue, based on theFAID program measurement, that affectedhis performance. This was predominantly asa result of his personal fatigue strategiesbefore and during the passage and;

4. did not provide the OOW with sufficientclear, unambiguous, instructions regardingthe course between Eel Reef and Piper Reefand made assumptions as to the OOW’sactions that were not justified.

The report also concludes that the OOW:

1. did not maintain an effective visual watchand allowed Doric Chariot to stray from theintended course;

2. did not adjust the ship’s course to follow theroute drawn on the chart;

3. did not fix the ship’s positions at intervalsthat were consistent with safe navigationand;

4. did not fully understand the pilot’s intentions.

Additionally,

1. The bridge resource management exercisedby the pilot and the OOW was ineffective.

The report makes three recommendationsinvolving clearer understanding between pilotsand officers; a fatigue management policy bypilots; and a paper to the IMO.

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Sources ofInformation

The master and officers of Doric Chariot

The pilot and Torres Pilots Pty Ltd

Reefcentre, Hay Point Queensland (QueenslandTransport)

Australian Maritime Safety Authority (AMSA)

Chios Navigation (Hellas) Ltd

AcknowledgmentThe Inspector is grateful to Interdynamics PtyLtd (www.interdynamics.com) for the computerprogram, FAID 330E, which was used duringthe analysis of the fatigue factors.

Certain reproductions of chart sections in thispublication are reproduced by permission of TheAustralian Hydrographic Service.

© Commonwealth of Australia 13 October 2000. Allrights reserved.

Other than for the purposes of copying thispublication for public use, the chart information fromthe chart sections may not be extracted, translated, orreduced to any electronic medium or machinereadable form for incorporation into a derivedproduct, in whole or part, without the prior writtenconsent of the Australian Hydrographic Service.

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Narrative

Doric ChariotDoric Chariot is a Greek flag, ‘panamax’ sized,geared bulk carrier. The ship was built byHyundai Heavy Industries in Ulsan, SouthKorea in 1994. It is 224.97 m in length overall,has a beam of 32.25 m and a moulded depth of19.00 m. The ship has seven cargo holds locatedforward of the accommodation superstructure ina standard bulk carrier design. The holds areserviced by four 25T SWL1 cranes. The summerdeadweight is 73 350 tonnes at a draft of 13.765 m.

The bridge front is 189.12 m from the stem. Thebridge is a combined wheelhouse and chartroomwith a GMDSS2 communications centre to thestarboard side of the chart table. The bridge isequipped with the required navigational aidsincluding two JRC 8000 series radars (1 ‘x’band (3cm) and 1 ‘s’ band (10cm) with ARPA).The ship also has two GPS receivers (1 xFuruno GP-70 mark2 and 1 x JRC JLR-4110mark2). The GPS mainly in use (GP-70) has afacility for setting alarms for both cross trackand waypoint arrival.

The ship’s complement of 20 men consistedmainly of Greek officers and Filipino crew. Allthe crew were appropriately qualified withSTCW95 (Standards of Training, Certificationand Watchkeeping, 1995) certificates. Themaster and OOW had both made a number oftransits through the reef on Doric Chariot withvarious pilots. The ship had all the required ISM(International Safety Management) certificates,procedures and checklists.

Great Barrier Reef compulsorypilotage areaThe compulsory pilotage area of the GreatBarrier Reef lies between its southern extremityat 16°40’S, south of Trinity Opening and northof the port of Cairns, and 10°41’S, near EboracIsland, off the northern extremity of Cape YorkPeninsular. The compulsory pilotage area isabout 430 miles in length which, together withthe critical passage through Prince of WalesChannel and Varzin or Gannet passage, extendsthe pilotage to 480 miles and involves some 14alterations of course. It consists mainly ofrelatively narrow fairways and is complicatedby tidal effects and cross currents. The seasonalconcentration of fishing vessels and reducedvisibility in the ‘wet’ season (November-April)further increase the risks associated withnavigation in this area. Conversely, it offers asafe passage, sheltered from the sea conditionsexperienced outside the reef, and can also offerconsiderable savings in time and distance forvessels trading between the Australian east coastand bound to or from places west of the TorresStrait.

A single pilot has the conduct of the vesselthroughout the whole compulsory pilotage area.Recognising that a single pilot cannot be on thebridge for the entire passage and perform to therequired level of alertness on a consistent basis,there are recognised areas in which pilots mayleave the bridge to rest or refresh themselves.The pilots’ ability to use these areas dependsupon weather/visibility conditions and thedensity of other traffic, particularly fishingvessels. The recognised areas are:

• Low Isles to Gubbins Reef;

• Egret Reef to Three Isles;

• Nymph Island to Howick Island;

• Flinders Island to Eden Reef;

• Clerke Island to Hannibal Island;

• Cairncross Island to Wyborn Reef.

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1 SWL is Safe Working Load

2 GMDSS is the Global Maritime Distress and Safety System

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FIGURE 3:Portion of chart Aus 835 showing grounding position

WA

SA

NT

Qld.

NSW

ACT

Tas.

Location ofincident

Vic.

1430

120

Actual ships track (red)

Intended route (orange)

0305 position

Grounding position

Reporting position ‘J’

Beacon

WaypointBeacon

Pilotage ServicesBefore 1 October 1991, pilotage was offered ona voluntary basis. Following recognition of theGreat Barrier Reef as a ‘Particularly SensitiveSea area’ by the International MaritimeOrganization, the Australian Governmentintroduced legislation making pilotage throughthe inner route3 of the Great Barrier Reef, northof 16° 40’S, compulsory for ships over 70 m inlength and for all ships carrying potentiallytoxic pollutants.

In 1993, responsibility for the regulation andadministration of pilotage in the Great BarrierReef was transferred, by ministerial agreement,from the Queensland Department of Transportto the Australian Maritime Safety Authority.AMSA focused its oversight on pilotagestandards, licensing, training, codes of conductand practice and other safety issues such asfatigue management and safety advisory notices.AMSA also conducts periodic audits of pilotsfor compliance with the Code of Practice,including the implementation of bridge resourcemanagement practices and also conducts regularthree monthly meetings with the pilots andpilotage provider companies to discuss on-goingsafety and operational issues. Recently (July2002) AMSA has introduced a system of ‘checkpilots’ .

To further enhance safety in the Great BarrierReef, a mandatory system of ship reporting wasintroduced, on 1 January 1997, jointly byAMSA and the Queensland Government. A shiptransiting the compulsory pilotage area isrequired to make some ten reports to Reefcentreat Hay Point, at predetermined positionsbetween Cape Townsend and Torres Strait. Shipentry points to the compulsory pilotage area,Torres Strait, Hydrographers passage and in thevicinity of Cairns are also monitored by radarfrom Reefcentre. The area around Piper Reefdoes not have radar coverage.

AMSA had earlier researched and planned, andis now in the process of establishing, an

alternate route for part of the Inner passagewhich provides more open water and fewercourse changes.

The controls governing service delivery andremuneration for Great Barrier Reef pilots werelifted with the repeal of Queensland legislationgoverning the pilotage service. Three serviceproviders set up in commercial competition.Two of these provide pilotage services in TorresStrait and the compulsory pilotage area and allthree compete for services in Hydrographer’sPassage.

Sea pilots operating in the Great Barrier Reefare self-employed. Individual inner route pilotscontract to a service provider. The serviceprovider is the direct link to the shippingcompany and assigns pilots to ships on an ‘inturn’ basis. The service provider also providesthe means of pilot transfer (either boat orhelicopter) and the pilots contribute a proportionof the pilotage fee to cover the costs of pilottransfer and administration.

The pilot provider also maintains a record of theships and hours worked and operates a ‘fatiguemanagement system’. One of the aims is toensure adequate time between assignments toallow a pilot to rest and recuperate incompliance with the AMSA Code of Practicewhile also equalising income for the variouspilots. In the case of the inner route, pilots musthave a minimum rest period of 24 hoursbetween ships, which must include uninter-rupted rest between 2200 and 0600. After threeinner route pilotages the rest period shouldinclude two nights rest between the hours of2200 and 0600.

In addition, the Marine Coast Pilots Code ofConduct requires a pilot to adhere to the restperiods prescribed in the Code of Practice.Other requirements of the code provide that:

Pilots must be adequately rested and mentallyalert in order to provide undivided attention to

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3 The inner route refers to the route to the west of the Great Barrier Reef, between the Reef and the mainland. The compulsory pilotagearea is the northern portion of the route, between Trinity Opening and the Northern extremity of Cape York.

pilotage duties for the duration of the passage. Itis a requirement that pilots should comply withrest period regulations as defined in the latestrevision of the Internal Handbook.

Pilots should prepare a Passage Plan for theintended pilotage passage and should discusswith the Master and Navigating Officer therelevant aspects. If necessary the plan should beupdated during the voyage and any significantamendments drawn to the attention of the Master.

Pilots must recognise the importance of BridgeResource Management in establishing a methodof familiarisation for the Master, and navigatingofficers. The information exchange must include:

• Discussion with bridge personnel on thepassage plan.

• Manoeuvring data of the vessel.

• Expectations with regard to draught, squat,tidal calculations and underkeel clearance.

• Procedures for recall when absent from thebridge.

• Encouragement from the Pilot for assistancefrom the Bridge Personnel.

• MCP Pilots shall include with Voyage Plansan emergency contingency plan to cover:

1. A vessel incident.

2. Pilot illness.

• Pilots should recognise the importance ofprofessional development and the need forkeeping up to date with changing circum-stances and technology. Pilots shouldtherefore ensure that there is regular consul-tation with bodies such as AMSA, GreatBarrier Reef Marine Park Authority andothers.

The pilot assigned to Doric Chariot on 26 Julyhad joined Reef Pilots in September 1993. Hewas already an experienced mariner withservice as master on the Commonwealthlighthouse ships, based extensively in the GreatBarrier Reef. He was issued an AustralianMaster Class 1 Certificate on 27 February 1991.The pilot qualified for ‘open’ AMSA pilotagelicenses covering all areas (Great North EastChannel, the inner route compulsory pilotagearea and Hydrographers Passage) by May 1994.

At the time of piloting Doric Chariot he wasproperly qualified with appropriateendorsements. His medical certificate was validuntil 10 January 2003.

The incidentWhilst it is not a requirement, it is the policy ofChios Navigation (Hellas) Ltd, the shipmanagement company operating Doric Chariot,to engage a reef pilot from the final port of callbefore the reef passage, in this case Hay Point.

The pilot boarded Doric Chariot in the earlyafternoon of 26 July. He had piloted the ship onfour previous occasions in 1998 and 1999. Thepilot introduced himself to the master andofficers and then familiarised himself again withthe ship’s bridge layout and equipment. Hechecked the gyro compass for error and foundthat it was 1° high. He then discussed theproposed passage to Torres Strait with thenavigator and the master. The pilot carried hisprepared voyage plan, which included a set ofchartlets covering each section of the passage.The navigating officer (the second of the twosecond mates) had entered the ship’s courses inthe GPS receiver based on the waypoints fromthe passage plan of a previous pilot. The pilotand the master agreed to use the plan alreadyadopted by the ship for the coming voyage. Thecross track error for all the waypoints was set attwo cables (0.2 nautical miles). The navigatingofficer drew the courses on the chart as far asCairns, leaving the pilot to draw the courses forthe compulsory pilotage area.

At 1645 on 26 July 2002 Doric Chariot sailedfrom Hay Point, Queensland, carrying a cargoof 61 951 tonnes of coking coal bound forVisakhapatnam, India. The voyage would takethe ship firstly through the Great Barrier Reefcompulsory pilotage area, then to Singapore forsupplies and then on to India for the cargodischarge. The departure draft was 12.2 m evenkeel which is the maximum possible to allowthe ship to transit the Prince of Wales channel inTorres Strait.

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The voyage proceeded without incident, passingFitzroy Island at 2002 on 27 July and enteringthe compulsory pilotage area at about 2145.

Based on the ship’s normal service speed, theship would have reached Torres Strait on 29 July before there was sufficient under-keelclearance to transit Prince of Wales Channel.Rather than anchor, and to save fuel, the masterand pilot agreed to reduce speed to reach thePrince of Wales Channel at a suitable state oftide.

The pilot had the conduct of the navigationthrough the compulsory pilotage area. Thedifferent OOWs routinely plotted the ship’sposition on the chart, at about thirty minuteintervals, using various methods, includingvisual bearings, radar and GPS. Both radarswere operating at all times with the pilot mainlyusing the 3cm radar and the OOW using the10cm radar. In the 40 minutes prior to thegrounding, neither the pilot nor the OOW usedradar parallel indexing techniques. The masterattended the bridge for most of the morningsand evenings and oversaw the actions of thepilot and OOW to ensure that he was confidentin the efficiency of the bridge operations.

In the early part of the voyage the pilot assessedthe performance of the ship’s deck officers todetermine his options with regard to rest breaksduring the passage. They appeared competent tohim and the pilot was confident that, whenappropriate, Doric Chariot could be left in theircharge. Before leaving the bridge at any time,the pilot called the OOW’s attention to thecourse and a position at which he should benext called which he had clearly marked on thechart.

Just after midnight, on 29 July, the ship alteredcourse as planned to 331°(True), 332°(Gyro),off Cape Direction. The master, who was still onthe bridge at this time, satisfied himself as to the

ship’s position and the bridge operations andthen went below to rest. The night was fine andclear with a rising moon (81% full). The windwas from the south east at about 20 knots4. Thebridge was manned by the OOW, the pilot andan AB (seaman) acting as lookout and/orhelmsman as required.

After passing Restoration Island at about 0100,the pilot made a mark on the chart about threemiles before Eel Reef light and instructed theOOW to call him at that point. The pilot restedon the bridge daybed, sleeping from about 0100until woken by the OOW at about 0200. Atabout 0220, as the ship approached the coursealteration position off Eel Reef light, the pilotrequested a slight course alteration to starboardto 334°(G), to increase the sea room for asouthbound ship.

After passing the southbound ship at about0231, Doric Chariot, as anticipated, was about 2 cables (370 m) to the east of the track. Thelights on Inset and Piper Reefs were clearlyvisible ahead, with Inset Reef light fine tostarboard. The pilot ordered a course adjustmentto port to 326°(G), on a heading between thelights, so as to bring the ship back to the trackbefore the next Reefcentre reporting position. Afurther adjustment to 325°(G) was thensuggested by the OOW and agreed to by thepilot.

Once satisfied that the ship had settled on itsnew heading the pilot decided to sit down onthe bridge daybed and rest. At the ship’s currentspeed of 10.2 knots it was due at the designatedSRS5 position off Piper Reef at about 0330.

According to the pilot, he spoke with the OOW,visually pointing out the lights of Inset Reef andPiper Reef ahead. The pilot pointed out theposition of the reefs on the radar and then wentto the chartroom where he indicated on the chartto the OOW the position where he wanted to be

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4 20 knots=20 nautical miles per hour (about 37km/hr)

5 SRS is ship reporting system

called, which was at the next Reefcentrereporting position. According to the OOW thepilot showed him the islands on the radar butdid not point them out visually and pointed tothe Reefcentre reporting position (J), beforesitting down.

Unlike the earlier periods when the pilot rested,he did not mark the position on the chart wherehe wanted the OOW to call him. The pilotalleges that he told the OOW to adjust the ship’scourse as necessary to bring it back to thecourse line. He then took off his shoes andreclined on the settee on the port side of thewheelhouse.

The OOW maintained his lookout solely byradar. In so doing, he mistakenly identified theecho of Piper Reef light as Inset Reef light. Atabout 0240, with the pilot’s concurrence andvery soon after he had sat down the OOW madea one degree course adjustment to port to bringPiper Reef fine on the ship’s starboard bow. At0305 the OOW plotted a position on the chartwhich indicated the ship was about two cablesto port of the track. No course adjustment wasmade.

At about 0320 the lookout went below to carryout a safety and fire patrol of the engine roomand accommodation spaces. This was a routinetask that the master required should beconducted every watch. There was no othertraffic in the area and the visibility was good.The OOW judged that this was a suitable timefor the lookout to conduct his ‘rounds’.

At about 0325 the OOW again made a courseadjustment to port, a further two degrees thistime, still on the basis of his mistaken identifi-cation and without plotting the ship’s position.The ship was now steering 322°(G) and wasabout 2.2 miles from the edge of the reef.

A little before 0330 the alarm on the HF/MFDSC (high frequency/medium frequency digitalselective calling) receiver was activated and theOOW went to the GMDSS equipment to checkand acknowledge it. The alarm was false and hecancelled the alarm and checked the alarm

display. He then went to the chart table andchecked the chart for details of the next course,before going to the lavatory. When he returnedto the bridge he saw the radar echo of the lighton Piper Reef (which he still believed was InsetReef) was still to starboard. The OOW calledthe pilot saying that the ship was at thereporting position. The pilot replaced his shoesand then got to his feet.

When the pilot stood up and looked at the ship’srelative position and heading with reference tothe two beacons at Piper and Inset Reefs (bothout to starboard), he immediately realised thatthe ship was to the west of the two-way routeand approaching Piper Reef. He ordered ‘hard-a-starboard’. The OOW changed to handsteering and applied the helm order. The pilotcould now see, in the moonlight, the breakingwater on the southern side of Piper Reef closeahead. He realised that the ship would notachieve a rate of turn necessary to clear theshoal water so ordered full astern on the engine.The OOW put the engine to full astern and thencalled the master. The ship started to swing tostarboard. The ship’s head swung through anangle of 18° to starboard, due to the action ofthe rudder and astern engine movement, butwithin about one and a half minutes the shiptook the ground to the south of Piper Reef light.

Doric Chariot grounded at about 0335, 0.52 miles south from Piper Reef lightbeacon on a heading of 343°(G), in position 12° 15.593'S 143° 15.038’ E by the ship’s GPS.The high water at Piper Reef was at 0001 at apredicted height of 2.3 m and the next lowwater was at 0741. The tide at Piper Reef hadbeen ebbing for about 31⁄2 hours.

The master arrived on the bridge just afterDoric Chariot took the ground. On his arrivalon the bridge, the master asked about thesituation from the OOW and pilot. He thenfixed the ship’s position on the chart andordered the ship’s main engine stopped.

Reefcentre was informed and the ship’s crewwere instructed to start checking the state of theship’s tanks and engine room equipment.

8

Soundings around the ship’s side were taken toestablish the grounding situation moreaccurately.

Salvors arrived on the ship on the morning of 30 July 2002 and began assessing the situationand the possible actions. It was decided that anyrefloating attempts would be delayed until thenext suitable high tide on Sunday 4 Augustwhen tug assistance would also be on the scene.

Although the initial attempts to float the shipwere not successful, Doric Chariot wassuccessfully refloated at 1747 on 6 August. Theship was then anchored about 4 miles north ofPiper Reef whilst a full assessment of itscondition was made.

A detention order by AMSA was lifted at 1530on 7 August 2002 after the ship was declaredseaworthy and it continued its voyagenorthward with another pilot.

9

10

FIGURE 4:Photograph taken from starboard bridgewing of Doric Chariot with Piper Reef light beacon in the distance

FIGURE 5:Aerial photograph of Doric Chariot aground with Piper Reef beacon in the foreground

Comment andanalysis

EvidenceThe ATSB safety investigation was significantlycomplicated by the number of other governmentagencies seeking to exercise jurisdiction for thepurpose of initiating a criminal prosecution orregulatory response. At the date of publicationlegal proceedings were ongoing.

Interviews were conducted with the master andofficers on board Doric Chariot on 31 July. Thepilot was interviewed in Cairns on 2 August.There were significant differences in theaccounts given by the OOW and the pilot inrelation to what the OOW was told by the pilota little after 0230.

Records of the working hours, as provided, ofthe master, OOW and pilot were assessedagainst the Fatigue Audit InterDyne (FAID)fatigue modelling program, developed byInterdynamics in collaborative partnership withthe Centre for Sleep Research at the Universityof South Australia. The pilot’s work historysince September 1993 was supplied by AMSAand the pilotage provider company. The fatiguemanagement plan supplied by the pilot providercompany was also reviewed. Audio tapes fromReefcentre were checked to verify radiocommunication information.

The night was fine and clear with a ‘pleasant’temperature. The wind was from the southeast,force 4-5 (11-21 knots). There was no swell.

No machinery or equipment failure on boardcontributed to the grounding. The lightsmarking Piper Reef and Inset Reef were alsooperating with the correct characteristics.

The log book and other ship’s documentationwere examined. There is no accurate contempo-

raneous record of the time that the engine wasput from full ahead to full astern, at about 0334.

Copies of the charts in use and the courserecorder chart were analysed. The courserecorder was assessed as indicating 1° high(same as the gyro) and 5 minutes fast of UTC(Coordinated Universal Time). The evidencefrom the course recorder shows a one degreeadjustment of course from 325°(G) to 324°(G)at 0240 and a two degree alteration at 0325 to322°(G). The course recorder trace suggests thatfull starboard rudder was applied at about0335:12, but no appreciable heading movementoccurred for about 30 seconds. Thereafter theship turned to starboard at a rate of 20°/min.

The masterThe master left the bridge after Doric Chariothad passed Wye Reef and Cape Direction. Heleft the bridge in the charge of the pilot, OOWand helmsman/lookout.

In addition to the Company Standing Orders,the master had issued his own supplementarystanding orders. These were consistent with thecompany’s orders and the requirements ofChapter VIII of the International Convention onStandards of Training, Certification andWatchkeeping for Seafarers, 1978 (as amendedin 1995).

As the ship was not passing through arecognised rest area the master had no reason tosuspect that the pilot would not be exercisingdirect control over the conduct of the vessel.The visibility was clear, the weather fine and thebridge watch was properly constituted. Thecourses were drawn on the chart and had beenagreed between the pilot and the master. Thecourses and waypoints had been programmedinto the GPS and the requirement to report toReefcentre at Piper Reef had been noted on thepassage plan. The weather was fine and clearand the situation appeared well under controlwhen the master went below just after midnight.

There was no apparent reason for the master toremain on the bridge.

11

Actions of the OOW – 0235 to0335According to the OOW, at about 0235 the pilotwent to the radar and pointed out the reefsahead. Then, on the chart, the pilot pointed tothe Reefcentre reporting position (position J)and instructed the OOW to call him at thatpoint.

The OOW spoke English well and thepossibility that he was unable to understandinstructions, or was unable to articulate arequest for clarity, is unlikely.

A short time before the OOW called the pilot,he was distracted by the alarm on the digitalselective calling component of the GlobalMaritime Distress Safety System (GMDSS).The alarm was spurious. He then went to thelavatory at the rear of the bridge, the door ofwhich is directly behind the chart table, adjacentto the internal bridge entry door. Thesedistractions detracted from his watchkeeping.However, it appears that this neither delayed theOOW in calling the pilot, nor influenced hisperformance in general.

The OOW roused the pilot at about 0330 byshaking his knee. Doric Chariot was in aposition roughly abeam of the reporting position‘J’, but displaced nearly one mile to the west. Atthis time Doric Chariot’s bow was about 1160 m or 3 minutes 40 seconds in time fromthe shoal water at the southern extremity ofPiper Reef. The OOW was quite unaware oftheir situation.

About 55 minutes earlier, at about 0235, afterthe pilot went to sit down on the bridge settee,the OOW had been left with a simple, routinetask of maintaining the ship on track. At 0240,without fixing the ship’s position, he adjustedcourse one degree to port to a heading of324°(G), assessing the alteration relative to theship’s head and (he thought) Piper Reef. He hadto call the pilot at the next Reefcentre reportingposition, 1.2 miles before Piper Reef. In thehour and five minutes between Eel Reef and thegrounding, the OOW fixed the ship’s position

only once, at 0305, using a radar range andbearing from First Stoney Point, 4.5 miles on the port beam.

The 0305 position is about 0.2 miles south andwest of the track programmed in the DoricChariot’s GPS set. The cross track error (XTE)alarm had been set at 0.2 miles and should haveactivated at about this time, whilst the ship wasstill 5.6 miles from grounding on the reef. It is astrong possibility that the alarm prompted theOOW to fix the ship’s position at 0305. TheXTE alarm can only be silenced by pressing the‘clear’ button (or removing the alarm inducingcondition). After the audible alarm was silencedthe display still indicated the continuing alarmcondition by a small ‘XTE’ light in the topcorner. The GPS XTE audible alarm did nothave a time-dependent recycle function, that isit would not ‘sound’ again unless it was resetand reactivated.

The OOW had adequate time to adjust thecourse, had he had a proper appreciation of theship’s position relative to the intended track andthe passage between Inset and Piper Reefs.From the time of fixing the ship’s position hehad about 30 minutes to react, had he realisedthe significance of the alarm. In fact at 0325,again without plotting the ship’s position, healtered a further 2 degrees to port to a headingof 322°(G).

Chios Navigation (Hellas) provide standingorders and check lists for ‘Safety ofNavigation’. In the OPERATIONALGUIDANCE FOR OFFICERS IN CHARGEOF NAVIGATIONAL WATCH (form No. D07-003), the following guidance is provided:

2. During the watch the course steered, position andspeed shall be checked at sufficiently frequentintervals, using any available navigational aidsnecessary, to ensure the ship follows the plannedcourse.

Form No. D07-005, a “CHECK LIST FORNAVIGATION IN NARROW WATERS”, asks:

6. ‘Is the ship’s position being fixed at regularintervals?’

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These guidelines mirror the InternationalChamber of Shipping’s Bridge ProceduresGuide and the requirements of Chapter VIII ofthe International Convention on Standards ofTraining, Certification and Watchkeeping forSeafarers, 1978 (as amended in 1995). Nomention is made in any guide as to whatfrequency of fixing would qualify as ‘regularintervals’. It is reasonable that the decision ofwhat constitutes ‘regular’ should be left to theprofessional judgement of the master and theofficer of the watch. In the Inspector’s opinion,however, in the compulsory pilotage area of theGreat Barrier Reef, fixes every 30 to 35 minutesdo not meet the test of reasonable frequency,particularly in the absence of the pilot.

Although the night was fine and clear and thetemperature ‘pleasant’, the OOW maintained hismonitoring of the ship’s progress only bylooking at the radar display. On the radar hesaw, amongst other target returns, a return fromPiper Reef light and returns from the islands onthe west side of Piper Reef, Farmer Island (12 m above datum) and Fisher Island (14 mabove datum). The OOW misinterpreted thetarget return from Piper Reef as being that ofInset Reef and Fisher and Farmer Islands asbeing the return from Piper Reef. Hisadjustment of course at 0240, and indeed 0325,was on the basis of passing between the returnfrom Piper Reef and Fisher Island.

It is likely that the OOW spent some time at, orin the vicinity of, the chart table. There is astrong possibility that the GPS alarm at 0305stimulated him to fix the ship’s position. TheGMDSS equipment is adjacent to the chart tableand the bridge lavatory is immediately behindthe chart table. There is also a strong possibilitythat the OOW spent a significant amount oftime either at the radar, the GMDSS equipment,or at the chart table. What is clear is that he didnot study the course laid down on the chart orgive thought to the ship’s intended course andthe course made good.

Had the OOW fixed the ship’s position at morefrequent intervals and kept a proper lookoutahead it should have been obvious that his

interpretation of the radar picture was wrong.Any visual lookout from the bridge front andany examination of the chart must have been, atbest, cursory.

Actions of the pilot – 0235 to 0335The pilot stated that, after passing the southbound ship off Eel Reef, as Doric Chariot wasto the east of the intended track he set a courseof 325° to bring the ship back to the track.Before sitting down on the wheelhouse settee heshowed the OOW the lights of Inset and PiperReefs and pointed out that the ship was headingbetween the two lights. The pilot assumed that,once the track drawn on the chart was regained,the OOW would make the 3° course alterationto bring Doric Chariot on a heading betweenInset and Piper Reefs. While the instructions hegave the OOW are the subject of some dispute,the OOW had made such adjustmentspreviously under the pilot’s supervision.

From a position just west of Eel Reef light thepilot was seated in the wheelhouse. Although hedid not intend to sleep he made himself verycomfortable and, at some time in the hourbefore the grounding, he had done so. This isthe third grounding in the Great Barrier Reef,when a pilot had been on the bridge but asleep,to be woken minutes before, or as, the shipgrounded. (Peacock, Report No. 95 – NewReach, Report 147) In the cases of Peacock andNew Reach the pilots were in the pilot chairasleep. In the case of Doric Chariot the pilotwas reclining on a settee fixed fore and aftagainst the port side bulkhead of thewheelhouse, just aft of the bridgewing door.

The presence of the pilot on the bridge wouldnormally indicate that the pilot has directcontrol of the conduct of the ship, and the roleof the OOW is one of monitoring the pilot’sactions. A pilot resting on the bridge introducesa degree of ambiguity in the role of the pilot.Who has charge of the navigation? Is the pilotawake or asleep? Will he be irritated if disturbedif he is asleep? Sitting on the settee the pilot

13

could not see ahead, but neither was heobviously detached from the conduct of thepassage and the bridge activity.

In submission the pilot stated that he hadhanded the conduct of the vessel to the OOW.Provided the OOW maintained the ship oncourse there was no reason for the pilot not torest or even have a short sleep. However, in theinspector’s opinion, the pilot was engaged toconduct the ship through the whole of the innerroute. However he managed this task heretained the conduct of the vessel as contractedto the master.

What is apparent is that the instructions givenby the pilot were inadequate, or deficient, inthat he did not tell the OOW why he hadselected the 325° heading or to return the shipto the planned heading once back on track. Hedid not say whether he was intending to sleep ornot. Although he did not intend to sleep, the riskof falling asleep was significant and, if he didnot intend to sleep, the pilot should have beenaware of the risk and made attempts to mitigateit.

The pilot had instructed the OOW that he becalled at position J. By choosing this position,the pilot had not allowed for any possible errorsor miscalculations. This position is so close toall the surrounding dangers that it would not bepossible to correct for any but the most minorand insignificant discrepancy in his plan.

AlertnessBoth the pilot and the OOW were operating atthe time of day associated with the low point ofthe circadian rhythm. Both men would havebeen prone to tiredness due to this time-of-dayeffect.

The pilot, by sitting down, removing his shoesand putting his feet up and then reclining on thesettee, without specific orders to the OOW toensure he stayed awake, was inviting sleep. Hehad been on the bridge since Eden Reef, a

period 101⁄2 hours. The temperature wascomfortable, and there was a quiet backgroundnoise. It was 0230 in the morning, a time whenthe diurnal human being has a naturalpropensity to sleep. All the factors wereweighted heavily against the pilot staying awakewithout some external stimulus.

The International Maritime Organisation,together with the International LabourOrganisation, defines fatigue as:

‘A reduction in physical and/or mental capabilityas a result of physical or emotional exertionwhich may impair nearly all physical abilitiesincluding strength, speed, reaction time, coordi-nation, decision making and balance.’

The Seafarers International Research Centredefines fatigue as:

‘Acute or chronic and encompassing tiredness,depression, sleepiness, stress, sleep quality anddisturbed circadian rhythms and boredom.

Acute fatigue can occur in a matter of hours andis usually the result of excessive or physicalactivity.

Chronic fatigue is reached when the ‘normal’period of sleep proves insufficient to restore theindividual’s working performance to its usuallevel. It is insidious and usually happens over aperiod of time. Persons suffering from chronicfatigue always perform below their personalbest.’

There are acknowledged to be four stages ofsleep6:

• Stage 1 - a transition between wakefulness andsleep, during which time the amplitude of thebrain waves decreases and the rate of brain waveactivity slows. A well rested person is easilyroused and may not realise that he/she has, infact, slept.

• Stage 2 - is a deeper, intermediate sleepassociated with slower metabolic and heart rates.A person is usually easily woken by sound.

• Stage 3 – a deeper sleep from which a person ismore difficult to wake.

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6 De Landre, J. Boag, C., & Fletcher, A., Asleep at the Controls, Flight Safety Australia, Vol 6 No.5, p.24, September-October 2002.

• Stage 4 – the ‘deepest’ sleep associated withlarge delta brain waves.

Waking somebody from stages 3 and 4 sleep isquite difficult. A person woken from these deepsleep stages will probably be groggy, disori-entated and confused and experience ‘sleepinertia’.7 The period of sleep inertia tends to beincreased by being woken suddenly. Also,people who are already sleep-deprived mayenter a state of deep sleep within 20 to 30minutes of the first sleep episode. In the firstthree minutes of wakening, decision makingperformance can be as low as 51 per cent of theperson’s best decision making ability.8

The stage of sleep that the pilot experiencedwhen awoken cannot be known with certainty.The stage of sleep would depend on when heactually entered stage one sleep and the degreeof fatigue that he was experiencing at the time.When he was aroused he first put on his shoesbefore standing to look forward out of thebridge front windows. It was only then that herealised that Doric Chariot was standing intodanger. Although this report cannot quantify anydelay that occurred between the pilot beingaroused and the order for full starboard rudder,there was almost certainly some delay, to agreater or lesser degree, due to a degree of sleepinertia.

The pilot’s work schedule andlevel of alertnessThe pilot had taken annual leave from the endof May until 9 July 2002. His first duty whenback from this leave was to conduct one shipnorth through the compulsory pilotage area, apassage of 37.25 hours. He flew south to Cairnsthen, at his own request, was not included in thepilotage roster again until 19 July.

On 19 and 20 July he conducted a bulk carrier,at 11.9 m draught, from Cairns to VarzinPassage, a duty time of 36.5 hours. He remained

at the Torres Pilot accommodation on ThursdayIsland until 1930 on 22 July, a period of justover two days, when he boarded the bulk carrierDoric Pride for the southbound, ballast passage,to Dalrymple Bay. He was on board for 62.5 hours. After disembarking, he booked intoa motel in Mackay for about 31 hours beforeboarding Doric Chariot at about 1500 on theafternoon of 26 July 2002. During this timeashore he visited some friends. He did not haveany daytime naps but that night did have anormal full night’s sleep.

The pilot remained on the bridge of DoricChariot from about 1500, throughout thedeparture from the port, until 1900. In all,between Hay Point and a point south of FitzroyIsland he had spent seven hours on the bridgeobserving the ship’s officers’ watchkeepingpractices and 21 hours resting. Thereafter, untilthe time of the grounding, the pilot spent 25 hours on the bridge (two of these sitting onthe settee) and 71⁄2 hours off the bridge (resthours).

The periods spent off the bridge coincided withrecognised areas of reduced risk in thecompulsory pilotage area where, providing theweather conditions and traffic allow, the pilot isable to leave the bridge.

The on-board decision to reduce speed ratherthan anchoring near Prince of Wales Channelhad the effect of lengthening the periods that thepilot was on the bridge but it also lengthenedhis rest periods. These factors should be takeninto account by the pilot in his personal fatiguemanagement strategy.

To assess the pilot’s possible exposure to fatiguethe simple test of ‘sleep credit/deficit’ wasapplied to the pilot’s waking and sleeping hoursas provided by him. This system credits eachsleep hour with two index points and debits oneindex point for each hour awake. This systemmakes no allowance for physical or mental

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7 ATSB aviation safety advisory notice SAN 20010244, 'Sleep Inertia' is a period of poorer task performance that results immediatelyafter awakening

8 Ibid Asleep at the Controls

effort or for circadian rhythms. A negative scoreonly indicates that the work hours warrantfurther examination.

Given the negative score, the pilot’s routine wasthen subjected to further examination using theFAID fatigue computer program.

FAID is a tool designed to help roster andmanage work hours so as to reduce the potentialfor excessive on-the-job fatigue levels. Thealgorithms within the program allow for both

the fatigue effect of the current shift’s hours ofwork and the cumulative effect of the workhours over the previous seven days. They alsoinclude an allowance for the ‘time-of-day’ effect(circadian rhythms). Fatigue programs areuseful tools and demonstrate a responsible andprofessional approach to safety management.However they can only be used as a guide. Theydo not make allowance for mode-specificenvironmental factors such as noise, light,vibration, or the proximity to the workplace forpilots and ship’s crews.

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FIGURE 6:Sleep credit/deficit analysis graph

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FIGURE 7:The best case

Completedsouthbound trip

280700

270700

Dips here areperiods of restbefore andafter Eel Reef

261500 pilot joinsDoric Chariot

FIGURE 8:The worst case

To examine the pilot’s fatigue using FAID a‘best’ and ‘worst’ case scenario was adopted.The best case uses only the hours of actual workon the bridge as the input whereas the worstcase uses all the waking hours as the inputparameters. The ‘true’ score probably liessomewhere between these two extremes.

The ‘best’ caseBoth of these FAID outputs were based on thedetailed information provided by the pilot at theATSB interview given a few days after theincident. The 'best' case shows a maximum ofabout 113 prior to the grounding.

The ‘worst’ caseIn this extreme example the fatigue score wasover 150.

In submission, both AMSA and the pilotprovider expressed doubt as to the validity ofthe data used by the Inspector. The pilot hadprovided them with a copy of his 'pilotage hourslog', a form the pilot is required to completecontemporaneously with his passage and returnto the provider after each voyage. This formshowed different hours of work and resulted inthem computing an index score of about 80.

Though there is some subjectivity about whathours are entered into the program, the resultswere such that, in combination with all the otherfactors available for examination, the Inspectoris satisfied that the pilot was suffering from theeffects of fatigue and also, immediately prior tothe incident, a sleep inertia effect (see page 15).In addition to the time-of-day effect, this was inpart due to his own management of his hours upto the time Doric Chariot entered thecompulsory pilotage area. For instance, afterleaving his previous vessel he elected to visit afriend rather than try to sleep. However, fewpeople can sleep at will even when aware offuture demands on their time.

The hours of work of the master and OOW, assupplied, were also examined using the FAID

fatigue program, but in neither of these casesdid it positively identify fatigue as an issue.

Bridge resource managementFully utilising all the assets, particularly thehuman assets on a ship’s bridge, reduces the riskof a ‘one person’ accident. The basis of BRM isto maximise the involvement and contributionof all persons on the bridge, utilising the skillsand experience of the ship’s staff and a pilot, ifembarked, together with the ship’s equipment totheir best effect. BRM is now an acceptedsystem for reducing risk factors and increasingthe safety and efficiency of navigation. The keyto effective BRM is communication between allthe parties involved.

In the Advisory Note to Coastal Pilots (3/99),‘The Use of Passage Plans’, AMSA drew theattention of pilots to the requirement of theSTCW Convention for ships to plan passages.The Advisory Note opined that a ship’s passageplan would not have the details required toensure safe passage in the compulsory pilotagearea in all circumstances. The Note remindedpilots of the need to maintain their own passageplans.

BRM depends on a two-way exchange ofinformation covering any limitations on theoperational status of the ship and the role thatthe individuals play. The pilot had his ownextensive passage plan, including chartlets. Theplan already adopted by the ship was verysimilar to the pilot’s own and any variation wasnot significant. However, in adopting theprevious pilot’s plan, and not using his own, theexchange of information was abbreviated. Thepilot did not specifically refer the master or theofficers to the areas of the route that were, in hisview, the areas of greatest risk.

The issue of pilots briefing ships’ bridge crewson their (the pilot’s) passage plan is one thatelicits a variety of opinions. It is argued thatexpecting to brief the master and all officers inone meeting is impracticable, given the differing

18

duties that officers have when sailing or arrivingin port. In long passages the officers may forgetcritical instructions. Some pilots favourprogressive briefing as the voyage progresses.What is important is that those on the bridgehave a shared concept of the ship’s route overthe hours to come and the actions that must betaken to achieve the aim. None of this isdifficult or particularly complex, but it is veryimportant.

The evidence indicates that, on the morning of29 July, the OOW did not properly understandthe pilot’s intentions (though he did not expressany doubt). That he should have done, and thata qualified and competent officer should haverecognised the intention from the chart, cannotbe disputed. However, people do make mistakesand their performance can be affected bydistractions, misunderstandings and attitude, allof which may be compounded by time-of-dayeffects and hours on duty.

Previous accidentsSince 1985 there have been 18 incidents9

involving trading ships over 70 m in lengthwithin the current compulsory pilotage area.There were 10 groundings and eight collisions,seven of the collisions involved fishing vesselsand one a patrol boat.

Between 1 January 1985 and the introduction ofcompulsory pilotage on 1 October 1991 therewere 10 reported incidents within the area. Inthe eleven years since the introduction ofcompulsory pilotage there have been eightincidents, four collisions and four groundings.This accident rate of 0.727 per year in the GreatBarrier Reef since the introduction ofcompulsory pilotage is comparable with the

similar Chilean pilot service which has a rate ofabout 0.771 serious groundings per year10.

Of the eighteen incidents recorded since 1985all but one have occurred north of BarrowIsland. Eleven of the incidents have occurred inthe area between Eden Reef and Clarke Island.Since 1 October 1991, six of the eight incidentsoccurred between Eden Reef and Clarke Island,five between the hours of 2230 and 0400.

It is self-evident that individuals could notmaintain an effective presence on the bridge forthe full extent of the compulsory pilotage areaand the critical passage through the Prince ofWales Channel and Varzin or Gannet Passage.The six recognised rest areas are designed tohelp manage the pilots’ performance and reducethe effects of fatigue. The extent of the restareas is about 27 per cent of the total length ofthe pilotage. The problem is that the rest areathat gives the longest rest opportunity is at thesouthern extremity of the pilotage area. Otherrest areas, depending on the ship’s speed, allowbreaks in the order of one hour to 11⁄2 hours. Theinner route between Eden Reef and ClerkeIsland (Cape Grenville) is 141 miles in lengthand is the longest part of the passage without arest area.

The presence of an alert pilot does not removeall risk of a marine accident. The experience ofpast groundings and collisions in the GreatBarrier Reef could support an argument that toreasonably guarantee a fully alert pilot at alltimes, ships should carry two pilots workingalternating watches. Although such anarrangement would possibly reduce some riskfactors during the passage, it would not removeall risk as evidenced by the Chilean experience.And such a regime could possibly introduce

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9 This figure does not include the grounding of a navigational aids ship engaged in work in and around Mid Reef in 1993.

10 In the Chilean Pilotage Service, two pilots, alternating time on the bridge, pilot ships over 1060 miles. The passage experiences verystrong cross currents and two areas where a ‘tidal window’ is necessary for the passage. The service experiences an average of 2.41groundings per year of which 70 per cent are minor‘touching bottom’ incidents which do not result in damage. The weather conditionstend to be more extreme than in the Great Barrier Reef.

different risks such as greater levels of boredomand issues of pilot recruitment andremuneration. The case for two pilots is notclear cut and would require careful and detailedassessment.

Safety actionsThe Australian Maritime Safety Authorityerected a radar transponder beacon (RACON) atPiper Reef in response to this incident.

The issue of pilot fatigue and options to addressthe lengthy passage between Heath Reef andEborac Island is under active consideration bythe Great Barrier Reef and Torres StraitShipping Management Group, as part of itsbroad ranging analysis of all factors involved inshipping incidents in the Great Barrier Reef.This includes assessment of a wide range ofmeasures to reduce the risk of incidentsoccurring, including pilotage levels, newtechnologies, education and awareness programsand vessel traffic systems.

Although AMSA has previously reviewed theparticular factors applying to this part of thepassage, this matter will be revisited and will beaddressed at the next scheduled meetingbetween AMSA and pilots in September 2003.The meeting will consider if there is a need fora common safety and fatigue reduction strategyfor the area. However, AMSA is of the view thateach passage is uniquely affected by weather,nature of ship and cargo, time of day, density ofshipping and other factors. It is therefore theprimary responsibility of the pilot, in consul-tation with the master, to determine the bestfatigue reduction strategies in light of thesefactors when formulating the agreed passageplan for the particular voyage.

Drugs and alcohol The Inspector is satisfied that neither alcoholnor drugs, prescribed or illicit, were taken byany of those involved in the grounding.

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Conclusions

These conclusions identify the different factorscontributing to the incident and should not beread as apportioning blame or liability to anyparticular individual or organisation.

All shore-based and shipborne navigational aids,the ship’s engine and the steering functioned asdesigned. On the evidence available, thefollowing factors are considered to havecontributed to the incident:

The pilot:1. sat down intending to rest but fell asleep, in

an inappropriate area of the pilotage passage;

2. instructed that he should next be called in aposition too close to the approaching dangersfor any successful corrective action to betaken, should it be required;

3. was likely to have been experiencing asignificant level of fatigue, based on theFAID program measurement, that affectedhis performance. This was predominantly asa result of his personal fatigue strategiesbefore, and during, the passage and;

4. did not provide the OOW with sufficientclear, unambiguous instructions regarding thecourse between Eel Reef and Piper Reef,making assumptions as to the OOW’s actionsthat were not justified.

The OOW:1. did not maintain an effective visual watch

and allowed Doric Chariot to stray from theintended course;

2. did not fix the ship’s positions at intervalsthat were consistent with safe navigation;

3. did not adjust the ship’s course to follow theroute drawn on the chart and;

4. did not fully comprehend the pilot’sintentions with regard to both his sleep/restand his navigational requirements.

Additionally:

1. The bridge resource management exercisedby the pilot and the OOW was ineffective.

21

22

FIGURE 7:Doric Chariot: Events and causal factors chart

Even

ts

Cond

ition

s

Inci

dent

MR20030032Ships’ officers should ensure that they fullyunderstand any intentions and instructions thatthey are given by a pilot prior to accepting‘active’ conduct from them. Pilots must ensurethat they are satisfied that ship’s officers fullyunderstand the pilot’s intentions. Pilots andships’ officers should both ensure that anyhandover of responsibility is unambiguous andcomplete.

MR20030033The Great Barrier Reef pilotage services shouldconsider adopting a fatigue management policythat predicts potential fatigue levels at keypositions in the pilotage task. Rather than onlyexamining a pilots fatigue level after a passage,the pilotage provider should, prior to allocatingthe job, use the FAID program to ensure that areasonable projection of the pilot’s fatigue scorewould not exceed a predetermined value at anypoint during the pilotage.

MR20030034Australia should submit a paper to the IMOseeking to amend the performance criteria ofGPS sets to include distinctive alarms andindicators. Such alarms, when silenced, shouldautomatically annunciate again after a specifictime period, unless the GPS is reprogrammed orthe alarm condition ceases.

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Recommendations

24

Submissions

Under sub-regulation 16(3) of the Navigation(Marine Casualty) Regulations, if a report, orpart of a report, relates to a person’s affairs to amaterial extent, the Inspector must, if it isreasonable to do so, give that person a copy ofthe report or the relevant part of the report. Sub-regulation 16(4) provides that such a personmay provide written comments or informationrelating to the report.

The final draft of the report, or relevant partsthereof, was sent to

The Great Barrier Reef pilot

Second mate Doric Chariot

Master Doric Chariot

The pilotage provider

The Australian Maritime Safety Authority(AMSA)

The ship owner Doric Chariot

The ship manager Doric Chariot

The following is an extract from the submissionreceived from AMSA.

…we believe the accuracy of the FAID scorequoted in the report must be questioned. To quotefrom the introduction to the FAID program “Arecent study indicated that scores between 80 and100 (that is, high fatigue) are equivalent to thepredicted level of work-related fatigue achievedafter 23-24 hours of continuous sleep deprivation(starting at 0800).”

The draft report states at page 16, in respect ofthe pilot’s duties on this occasion, that “In all,between Hay Point …the pilot spent 25 hours onthe bridge (two of these sitting on the setee) and71⁄2hours off the bridge (rest Hours).”

Our previous comments also identified the otheropportunities available for rest before and duringthe voyage by the pilot. Taken with the above,AMSA considers that the assessment that thepilot has a score between 130 and 150 iserroneous.

Regarding recommendation 2, again primaryresponsibility for managing fatigue rests with theindividual pilot. Regulation and policy can onlyprovide guidance and it is up to pilots to followappropriate practices. To assist pilots, AMSA isalready actively engaged in investigating withpilots and providers the improvements possiblewith predicting their fatigue levels. The types ofinitiatives being progressed are the use ofindividual FAID programs for each pilot that canbe kept updated during the passage task, and realtime reporting of the ship progress through theGreat Barrier Reef pilotage area that can bemonitored by AMSA.

Elsewhere, where appropriate, the text has beenchanged to correct the draft or reflect thesubmission.

25

26

Doric Chariot

IMO Number 9075670

Flag Greece

Port of Registry Piraeus

Classification Society Lloyds Register

Ship Type Bulk Carrier

Builder Hyundai Heavy Industries Co., Ulsan, South Korea

Year Built 1994

Owners Doric Chariot Corporation, Monrovia, Liberia

Ship Managers Chios Navigation (Hellas) Ltd

Gross Tonnage 38 779

Net Tonnage 24 372

Deadweight (summer) 73 350 tonnes

Summer draught 13.765 m

Length overall 224.97 m

Breadth 32.25 m

Moulded depth 19.00 m

Engine 1 x B & W 5S60MC

Total power 9 180 kW

Crew 20 (Greece, Bulgaria, Philippines)

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21 3

72 Independent investigation into the grounding of the Greek registered ship Doric Chariot at Piper Reef, North Queensland on 29 July 2002

ISS

N 1447-087X

ISB

N 1 877071 36 6

D.Chariot 09.03