Safety Lessons from Marine Incident Investigation (AMSA Report) No.14 – December 2022
On the morning of 24 April 2022, a fishing vessel ran aground on a reef between Bundaberg and Torres Strait. The master and two deck hands had been underway for six days prior to the grounding. The master was fatigued, having had little sleep given the watchkeeping schedule and the competency levels of the two deckhands. The investigation identified that the risk assessment for appropriate crewing including the management of fatigue and watchkeeping were inadequate. In addition, the passage planning/safe navigation was compromised by a lack of suitable electronic or paper charts.
At 0900 on 17 April 2022, a Class 3B fishing vessel commenced its voyage from Bundaberg to the Torres Strait via the inner route. This was the master’s first long voyage in command and the second deckhand’s first trip on a commercial vessel. The master arranged the bridge watches between himself and the senior deck hand in four hours on/four hours off watch rotations. The master chose to rest on the day bunk in the galley area rather than his cabin. As the deckhands did not hold certificates of competency, he felt he needed to be immediately available. The only rest the master had in the six days between departure and the grounding was four hours while anchored at Zoe Bay on 21 April. At about 0630 on 24 April, the vessel ran aground on Kay Reef while the master was on watch. The vessel contacted coral reef and came to rest on the keel. The Australian Maritime Safety Authority vessel Coral Knight responded and following an assessment for damage, the vessel was re-floated and subsequently detained. No crew injuries were reported.
The investigation identified the following contributory factors:
- The master was fatigued having been continuously on watch or on call to operate the vessel from the commencement of the voyage until it grounded.
- The owner was not able to provide the risk assessment used to determine the appropriate crewing for the voyage from Bundaberg to Torres Strait.
- The deckhands did not hold certificates of competency nor were experienced watchkeepers.
- The existing vessel crewing requirements allowed the vessel to operate with uncertificated crew, required only to hold a recreational marine driver’s license, to operate the vessel in certain circumstances if the master deemed them competent.
- The safety management system risk assessments and risk controls were inadequately implemented. A risk assessment on appropriate crewing for this voyage would have ensured appropriate controls were in place to manage the master’s fatigue.
- A ‘watch guard’ alarm, which was identified as a fatigue risk control measure, was not fitted.
- Nautical charts were not provided by the owner and no logbook was kept for the voyage.
This investigation identified that risk assessments and risk controls within the safety management system must be appropriate and implemented properly for the vessel to operate safely. The owner is responsible to ensure that an appropriate crewing assessment including consideration of fatigue and proper watchkeeping is critical to ensure crew continue to be fit for duty, to operate the vessel safely over long periods of time at sea. Additionally, adequate passage planning is an important aspect of safe navigation and must be part of the risk assessment within the safety management system.