The Australian Transport Safety Bureau (ATSB) has issued an investigation report into an incident where the pilot launch Corsair, retrieving the pilot from the outbound MV Rio Grande, ran aground on Point Lonsdale Reef after misinterpreting its course.
What happened
On the evening of 5 October 2023, the pilot launch Corsair was retrieving the pilot from the outbound container ship MV Rio Grande after it had departed Port Phillip. The transfer of the pilot to the launch took place offshore, about 4.2 km south-west of Point Lonsdale. Port Phillip Sea Pilots (PPSP) was the pilotage service provider and operator of the pilot launch. The pilot launch commenced its return to the entrance of Port Phillip at about 2307 intending to return to the pilot station at Queenscliff, inside the bay. At about 2310 and when about 2.3 km south-west of Point Lonsdale, the coxswain commenced a slow course alteration to port of about 18º. Corsair was about 760 m from Point Lonsdale Reef when it steadied on a course towards the reef. Corsair was west of the location intended by the coxswain and subsequently ran aground on Point Lonsdale Reef at about 2313 travelling at 24 knots.
What the ATSB found
It was found that the coxswain of Corsair misinterpreted the leading lights marking the entry to Port Phillip and navigated to the west of their intended course through the entrance. The return to Port Phillip following offshore pilot transfer was a routine activity which had been performed by the coxswain on many occasions. On this night, their perception of navigational lights on Shortland Bluff was probably influenced by their expectations of what they would normally observe.
The likelihood of human error can be reduced by using protective systems of technology, other crew resources, and procedure. In this instance, the coxswain’s navigation of Corsair back to the entrance was predominantly visual with limited reference to onboard equipment to confirm the vessel’s approach. The other launch crew member, a deckhand, was also not actively involved with the vessel’s navigation.
A vessel’s safety management system provides the structures and guidance to support a consistent approach to vessel operations. It was found that the pilot launch safety management system and procedures could be improved with guidance to the launch crew on operational practices for navigation through the entrance to Port Phillip and the effective use of the launch’s equipment and deckhand.
It was also found that training material for launch coxswains contained limited detail on course content and assessment criteria, and training records were incomplete. There was also no refresher crew training in navigational practices.
Although not considered to have influenced this occurrence, additional findings are made on the potential for review by Safe Transport Victoria of the local knowledge certification requirements for masters of domestic commercial vessels operating in Port Phillip Heads.
Contributing factors
- The launch coxswain misinterpreted navigational aids marking the entry to Port Phillip and navigated to the west of safe passage through the entrance. The coxswain had transited the Heads many times and their perceptions were probably influenced by the expectations of what they would normally observe.
- The launch coxswain relied on their visual observations of navigational aids and did not make effective use of available on-board navigational equipment for the return of Corsair through the entrance to Port Phillip.
Other factors that increased risk
- It was probably not normal practice for launch deckhands to actively support launch navigation. In addition, the layout of navigation displays on Corsair did not allow for easy referral by the deckhand.
- The safety management system for Corsair did not include detailed guidance and reference material for the safe navigation of Port Phillip Heads, the effective use of launch navigational equipment and the role of the launch deckhand in supporting safe navigation.
- Documentation supporting the training and competency assessment of launch coxswains was limited in detail and training records were incomplete.
Other findings
- The navigation equipment on Corsair had additional (unused) features that could assist launch navigation through Port Phillip Heads.
- Regulation did not require local knowledge certification of masters of non-passenger-carrying domestic commercial vessels (DCV) operating in the high-risk area of Port Phillip Heads. This differed from the remainder of Port Phillip for which local knowledge certification was required for masters of non-passenger-carrying DCV with a length of greater than 12 m. There was an opportunity for Safe Transport Victoria to review the requirement for Port Phillip Heads.
