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Container ship crash caused by poor communications, distracted bridge team
A Maersk container ship collided with a tall sailing ship in Port of Fremantle, Australia, due to inadequate communications between the pilots, bridge team and tugboats
Container ship Maersk Shekou collided with tall ship Leeuwin II in the Port of Fremantle, Western Australia, in August 2024 due to ineffective co-ordination, communications and monitoring by the vessel crew and harbour pilots on board.
The Australian Transport Safety Bureau (ATSB) found the primary pilot did not communicate with the helmsman and co-ordinate enough with four tugboats assisting the 333-m, Singapore-flagged ship to prevent the accident.
Its investigators reviewed audio from the ship’s bridge taken from the vessel data recorder and identified that the pilot did not provide the helmsman with a planned port 10° helm order to turn into the inner harbour, and this went undetected by the rest of the bridge team.
“This meant that as the pilot attempted to use the main engine and four attached tugs to turn the ship, the helmsman attempted to maintain the ship on the previously instructed heading of 083°, rigorously opposing the ship’s planned turn,” said the ATSB in its report.
As a result, Maersk Shekou continued towards Victoria Quay and collided with Leeuwin II which was berthed at the quay, before the stern contacted the wharf edge and containers struck the roof of a museum.
Leeuwin II was damaged and two crew who were disembarking along its gangway when the collision occurred sustained minor injuries. The container ship sustained minor damage, including a hull breach, but its crew and the pilots were uninjured.
Chief commissioner Angus Mitchell said the ATSB found the ship’s bridge team “ineffectively implemented bridge resource management practices” and they failed to adequately monitor, or challenge, the ship’s turn and position in the channel.
“A properly functioning bridge team requires that all its members maintain a shared mental model to actively monitor a ship’s progress,” Mr Mitchell said. “This relies on relevant information being conveyed to all members of the team, and actions that are incorrect being identified, communicated and rectified immediately.”
The ATSB’s investigation also found the secondary pilot was distracted from monitoring responsibilities as they were engaged in a non-essential mobile phone call as the ship was transiting a critical area in the entrance channel.
“This meant they were distracted from their monitoring role and did not identify that the lead pilot had not ordered a course alteration, and the helmsman’s actions were opposing the ship’s planned turn,” said Mr Mitchell.
“This highlights the importance of minimising distractions on the bridge, especially during critical stages of a passage.”
The investigation also identified that making fast the supporting tugs was delayed, resulting in the bridge team, including the pilot, being engaged with the final tug’s attachment just as the ship approached the wheel over point for the inner harbour entrance channel.
“This increased bridge team workload at the most critical stage of the passage,” said Mr Mitchell.
The ATSB also identified several risk controls established by Fremantle Ports to ensure the safe entry of large container vessels had not been adequately implemented, although these did not all directly contribute to the collision.
“These included entering the inner harbour channel without all tugs being secured, prior to sunrise, and well in-excess of the operational wind limits – all of which contravened documented procedures,” Mr Mitchell said.
He added that these factors collectively reduced the effectiveness of the port’s risk control measures and increased the risk of future safety occurrences.
Both the port and the pilotage provider, Fremantle Pilots, have committed to implementing a range of safety actions in response to the investigation.
Concluded Mr Mitchell, “The dynamic nature of marine operations often results in conditions varying from those expected, and it is essential any associated risks and consequences – particularly those affecting predefined and documented limits – are carefully reassessed when required, and any changes to the plan are effectively communicated between all concerned parties.”
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