The incident

At about 0530 on 9 February 2017, the passenger cruise ship L’Austral began its entry to Milford Sound with an authorised harbour pilot onboard. Because it was dark and there were no external visual navigation aids, the bridge team was using only the ship’s electronic navigation systems to conduct the pilotage.

As the ship was making a turn off Dale Point, the pilot lost awareness of exactly where the ship was, the direction in which it was heading and the effects of the wind and tide on the ship.

The L’Austral deviated well off the planned track and struck a stony bank near the shoreline of Milford Sound. The ship suffered scraping and indentation of the hull on its starboard side, but the hull was not breached and nobody on board was injured.

Findings

--> TAIC found that the ship’s crew on the bridge noticed the ship was off its planned track, but did not bring this to the pilot’s attention until it was too late to avert the grounding.

--> The Commission found that the bridge team were not making full use of the ship’s electronic navigation systems to ensure that the ship stayed on track.

Safety issues

  • The primary means for navigation on board the L’Austral, ECDIS, was not being used to its full potential as a tool for planning and monitoring the ship’s passage, and the crew were not fully conversant with its safety features
  • The standard of bridge resource management on board the L’Austral during the Milford Sound pilotage did not meet good industry practice
  • Conducting ‘blind pilotage’ with large ships in confined waters represented risks that had not been fully considered by Environment Southland, the regional authority that regulates maritime activity in the area.

The Commission repeated two previous recommendations to the ship’s operator (Compagnie des Iles du Ponant) and made one new recommendation to Environment Southland to address the safety issues.

New recommendations

To the Chief Executive of Environment Southland:

There are a number of measures that the regional council could take to better manage the risks to navigation safety within Fiordland, including: the provision of more navigation aids; better training and currency for pilots in blind pilotage techniques; and even prohibiting night navigation of certain passages if that were felt necessary.

On 22 June 2018 the Commission recommended that the Chief Executive of Environment Southland review the risk assessment for safe navigation within Fiordland and take the necessary action(s) to mitigate the risk of large cruise ships frequently transiting narrow passages with limited room for manoeuvring and with pilots on board during the hours of darkness or in other conditions of restricted visibility.

The Commission had previously found that poor bridge resource management under pilotage was a factor contributing to accidents involving two other ships in New Zealand. Their two reports had made several recommendations aimed at improving the standard of pilotage and making the transition of the pilot into the ship’s bridge team seamless.

Action taken

  • Environment Southland has set blind pilotage refresher training requirements, and is going to do a general navigation safety assessment in respect of increasing numbers of cruise ship visits to Fiordland (including pilotage in darkness and navigational aids).
  • The pilot company has sent pilots on blind pilotage refresher training.
  • The operator has restated expectations of masters and bridge crews for pilotage situations.

Lessons learned

  • A ship’s passage plan is more than just the planned track for the ship to follow. Every part of a ship’s voyage must be planned and all members of the bridge team be fully familiar with and agree to the plan. This is a cornerstone of good bridge resource management
  • Good bridge resource management relies on a culture where challenge is welcomed and responded to, regardless of rank, personality or nationality
  • ECDIS is a valuable aid to navigation. However, mariners need to fully understand and be familiar with all aspects of the system, particularly when using it for blind pilotage.

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