The ship hit a rock after different understandings between the harbour pilot and master led to a turn being taken late. Safety issues identified related to: the standard of bridge resource management, difficulties integrating the port and harbour risk assessments, and inadequacy of counting launch transits towards pilot proficiency for large ship transits through Tory Channel. Urgent recommendations were made in 2016.
Executive summary
On 27 January 2016 the Maltese-flagged passenger ship Azamara Quest was en route to the port of Picton in New Zealand’s Marlborough Sounds, with 652 passengers and 394 crew on board.
A harbour pilot boarded the Azamara Quest outside the entrance to Tory Channel at 0900. The master and pilot exchanged information and discussed the passage plan through Tory Channel to Picton, in particular the strong currents in the tight turn required on entry to Tory Channel. However, due to miscommunication the passage inwards began with the master and pilot having different understandings of how the first turn would be conducted.
As a result the turn was initiated late and the ship never achieved a sufficient rate of turn to avoid contacting Wheki Rock close to the northern shoreline. The ship struck the rock, causing minor damage to the hull and damage to one propeller. Nobody was injured.
The Transport Accident Investigation Commission (Commission) found that the bridge team had no common (agreed) understanding of the plan for the ship to make the turn into Tory Channel because the details of how the turn would be made and the influence the tide would have on the ship during the turn had not been clearly communicated. Therefore, with no agreed plan, the task of the bridge team monitoring the ship’s progress through the turn was set up to fail.
The Commission also found that the port company and pilot were relying on the pilot making five transits of Tory Channel using the port company pilot launch in order to maintain currency with the Pilot Training and Proficiency Plan, which did not meet the intent of the plan.
The Commission identified three key safety issues:
- the standard of bridge resource management on board the Azamara Quest did not meet the requirements of the company’s safety management system, or the standards in the various International Maritime Organization publications1
- Port Marlborough’s port risk assessment and Marlborough District Council’s harbour risk assessment could not be easily integrated, making it difficult to have one integrated risk assessment for the harbour
- the port company allowing its pilots to use transits made on the pilot launch count towards the requirements of Port Marlborough New Zealand Limited’s Pilot Training and Proficiency Plan created a risk of pilots not being sufficiently current to pilot large ships through Tory Channel.
The Commission made two new recommendations to address these safety issues.
The Commission has previously found poor bridge resource management under pilotage to be a factor contributing to accidents involving two other ships in New Zealand. The respective reports made several recommendations aimed at improving the standard of pilotage and making the transition of the pilot into the ship’s bridge team more seamless on a global level.
A key lesson arising from this inquiry is:
- safe navigation in pilotage waters is a shared task of the bridge team and the pilot. This accident highlights the importance of a comprehensive pilot/master exchange of information and ensuring it is communicated to the rest of the bridge team.
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Related Recommendations
On 2 August 2016 the Commission recommended that before allowing cruise ships to use Tory Channel in future, the Chief Executive of the Marlborough District Council review its harbour risk assessment for the safe navigation of ships through Tory Channel, and in doing so consider the safe navigation of cruise ships through Tory Channel as a separate risk. The new risk assessment should consider, but not be limited to, the following factors: - the limited number of piloted ships using Tory Channel make it difficult for harbour pilots to maintain currency
On 2 August 2016 the Commission recommended that the Director of Maritime New Zealand review Port Marlborough New Zealand Limited's Port Safety Management System and ensure that it has appropriate procedures in place to meet the requirements of its Pilot Training and Proficiency Plan and that the plan meets the intent of Maritime Rules Part 90: Pilotage.