Leeuwin II: Australian Transport Safety probe finds ‘distracted’ crew and pilots contributed to horror crash

Ineffective coordination and monitoring by the crew and harbour pilots on board a container ship that smashed into WA’s beloved Leeuwin II has been found to have contributed to the catastrophic collision. The Leeuwin II was destroyed and its crew forced to jump to safety when it was hit by container ship the Maersk Shekou as it entered the Port of Fremantle under heavy squall conditions on August 30 last year. The ship returned to the water late last month after more than a year of repairs. An investigation by the Australian Transport Safety Bureau, which analysed audio from the ship’s bridge, showed the “primary pilot did not provide the helmsman with a planned port 10° helm order to turn into the inner harbour, which 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,” the ATSB’s findings, handed down on Monday, said. “As a result, the Maersk Shekou continued towards Victoria Quay and collided with the Leeuwin II, which was berthed at the quay, before the stern contacted the wharf edge and containers struck the roof of the WA Maritime Museum. “The Leeuwin II was dismasted and two crew, who had been on board and were escaping via its gangway just as the collision occurred, sustained minor injuries. The container ship sustained minor damage, including a hull breach, but its crew and the pilots were uninjured.” ATSB chief commissioner Angus Mitchell said the ATSB found the ship’s bridge team, which comprised two pilots and the ship’s crew, “ineffectively implemented bridge resource management practices”. The agency said the bridge team 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 their 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 that the helmsman’s actions were opposing the ship’s planned turn,” Mr Mitchell said. “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.” Mr Mitchell added 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. However, he said 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,” he said. Mr Mitchell said these factors collectively reduced the effectiveness of the port’s risk control measures and increased the risk of future safety occurrences. The ATSB said both the pilotage provider and Fremantle Pilots “have committed to implement a range of safety actions in response to the investigation”. “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 pre-defined and documented limits — are carefully reassessed when required, and any changes to the plan are effectively communicated between all concerned parties,” Mr Mitchell said.