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Canberra Conference Unit




Press Conference


10:30 AM



Summary ID:



The Australian Transport Safety Bureau's, Martin Dolan, holds a press conference to release the final investigation report into the 3 April 2010 grounding of Chinese bulk carrier Shen Neng 1, off the coast of Queensland.

Interviewees: Martin Dolan, Australian Transport Safety Bureau's Chief Commissioner


Male 16+

Female 16+

All people




MARTIN DOLAN: Okay, ladies and gentlemen, if we're right to go. I'm Martin Dolan, the chief commissioner of the Australian Transport Safety Bureau and I'm here to talk about the release of our final report into the grounding of Shen Neng 1 at Douglas Shoal on 3 April 2010.

Before I start, I should make it clear that the role of the Australian Transport Safety Bureau is to investigate accidents and occurrences with a view to seeing what can be improved to prevent these things happening in future. We're explicitly prevented from allocating blame in any of these matters.

So the Shen Neng 1 had left Gladstone on 3 April around 11am with a full load of coal, bound for China. As well, it had nearly 1000 tonnes of heavy fuel oil, a large proportion of which was stored in tanks at the bottom of the vessel. And the plan was that the ship would navigate through the Great Barrier Reef north of Gladstone and then east north east of a place called North Reef Lighthouse. If you want to see the course, it's actually set out in page 11 of the investigation report.

The global positioning system of the vessel was set for that initial course, heading north and then east-north-east. At about 1.30pm, the second mate who was on duty, and the master decided to alter the ship's planned route slightly. Rather than heading directly north to head slightly more easterly, but still within the limits of allowed passages through that part of the reef.

The process of changing that planned route meant that the crew - in fact in changing that route, the crew did not alter the GPS settings, so they were still set for the original course, which led to some problems with alarms in due course.

At 3.30pm, the vessel altered to the new planned course. Shortly thereafter the global positioning system, the GPS, set off an alarm saying you're off course, because it was still programmed for the original course. But the crew was aware of that, and so they just switched off the alarm.

At 4pm the second mate handed over the watch to the first mate. They had a discussion about the changed planned course and what was going on, and that the GPS had not been reprogrammed. The first mate then was alone in the wheelhouse with a seaman acting as a lookout. This is the first time the first mate had navigated a vessel through this area and previously, he'd had an extremely busy time supervising the loading of the ship in Gladstone and had had approximately two and a half hours of sleep in the previous 38 hours. So fatigue was a significant element of what was going on here.

At about 4pm the ship moved into an area that was covered by a particular chart, Aus 820, a new chart. They'd previously been on Aus 819. But on the chart table on the vessel, the first mate didn't change to the new chart. So he did not have a chart that showed him a potential hazard, the reef that the vessel finally ended up grounding on.

At about four-thirty, the vessel reached the point where it should have changed course and headed east-north-east. But at that point, the chief engineer visited the bridge to check some engine revolution questions and this distracted the first mate who had intended to fix the ship's position at that time but decided to wait until 5pm to do so.

At 5pm he did check the position from the GPS, plotted it onto the chart, realised the vessel was on course to and very close to Douglas Shoal. Attempted to alter course but this was too late to make a difference. The ship grounded at about 12 knots, caused extensive damage to the hull including to the fuel tanks and some fuel was released into the environment as a result.

So what we have here is essentially a succession of quite simple and small errors on the part of a tired crew member leading to the grounding of the vessel. Our focus has been to find out contributing factors and therefore what can be done about them.

We identified essentially four key issues. The first was a lack of a fatigue management system on the vessel, the Shen Neng 1, to ensure that people keeping watch were actually in a fit state to do so. The second was that the ship's safety management systems did not have any procedures or guidance on how to use the global positioning system route planning facility, setting off alarms and so on, and how to deal with those when plans were changed to a different course for the vessel.

In the time leading up to the grounding, there was nothing external to the vessel in terms of the conditions or how the sea looked that gave any visual cues about the potential approach to a reef. So the underwater hazards navigation, including the shoal, were not visible.

And at the time of the grounding, there was no reef vessel tracking system in place in the sea area off Gladstone. It was in operation further north on other parts of the Great Barrier Reef, but was not in place in this area. This reef vessel tracking system is the capacity to actually see and monitor and send signals out to vessels if they go off track.

As a result of our investigation, we have issued two safety recommendations to the management company of Shen Neng 1 relating to those safety management system issues, fatigue management and passage planning. And we've also acknowledged that there is work in train by the Australian Maritime Safety Authority to extend the reef vessel tracking system to include coverage of the waters off Gladstone.

I want to thank the investigation team for what's been a comprehensive and thorough job and I'm very happy to answer any of your questions.

QUESTION: The safety recommendations you've made to the crew of the Shen Deng 1, how likely is it that they will take this onboard?

MARTIN DOLAN: We're confident that the management company will take this seriously and will take the necessary steps. We know that they will end up under scrutiny when they operate in Australian waters again and they will have to be able to show evidence that they have paid attention to these sorts of recommendations.

QUESTION: But they can't be forced upon them, even if they are in Australian waters?

MARTIN DOLAN: We have no power as an investigating agency to force anyone to do anything. We can make clear recommendations. The supervision of navigation of these sorts of vessels in Australia is by the Maritime Safety Authority and they do have the capacity to check the various systems of a vessel and to ensure there's appropriate compliance with standards.

QUESTION: You mentioned it briefly, but how was that crew member distracted when he was going to put in the GPS changes…?

MARTIN DOLAN: He wasn't meant to put the GPS changes in, he was meant to change course earlier, at about four-thirty. It was closer to 20 to five in fact when the key point of changing of course was.

So there was a distraction to the point where he should have been able to chart his position and therefore see where he was heading and the potential risk. He was distracted by the chief engineer arriving on the bridge and wanting to check something that was reasonable to the operation of the ship. But a tired person was therefore distracted from another thing he should have been doing.

QUESTION: You mentioned a number of - a combination of small errors. Is there any one that if it hadn't happened would have prevented this happening?

MARTIN DOLAN: I think it's a classic case where there's a sequence of things. Any individual one of these things should have had some sort of other protection to stop it happening. But it was a sequence of things going wrong that led to a major failure. Which is quite often what we find in the course of our investigations.

QUESTION: Two and a half hours of sleep in 38 and a half hours, how do you ensure that crew members would have improve sleeping patterns on a tight schedule like that?

MARTIN DOLAN: I think the reality is that the first mate is always going to be - have principal responsibility for the loading and therefore a recognition during loading that he is going to be getting not very much rest. And so the scheduling of watch keeping and so on later on should take account of that sort of risk to the vessel.

So it's how you look at what's going on that's causing fatigue and how you manage it, because the aim is that you don't get a fatigued person keeping watch on one of these vessels and responsible for its navigation.

QUESTION: So despite the investigation, because the recommendations don't have to be enforced, is it entirely possible that we could see the exact same thing happen again?

MARTIN DOLAN: We think it's unlikely, because there's a range of things in here, and the key thing that will make a difference in terms of an added protection in the system is the extension of the reef vessel tracking system to this area. So there'll be actually someone sitting, watching the courses of various ships and working out whether they may be going into places they shouldn't.

QUESTION: Have you previously recommended that that tracking system be extended, before this case?

MARTIN DOLAN: Not that I'm aware of. No. Mr Foley tells me we haven't previously recommended this.

QUESTION: So has this been a wake up call to other operators?

MARTIN DOLAN: [Laughs] Sorry, I'm just thinking fatigue, wake up call. It should be and what we are saying is that there should be consistent attention paid by people operating to the risk of fatigue. Fatigue can lead to a range of serious safety consequences. You need to have good systems in place and operating to manage the potential risk of fatigue.

QUESTION: Is there other parts along the Great Barrier Reef where there is a potential for the shipping companies to take short cuts where the tracking system should also be…

MARTIN DOLAN: We're satisfied that the extension of the vessel tracking system to this area off Gladstone meets the sort of risk that's been discovered in this case. I don't think it's reasonable to describe what happened as a short cut. The course that the vessel took - it was changed, but it was within the normal expectation of routes that you can take to get out of Gladstone. It's not shortcutting; it was just taking a different course as the most efficient way of getting out of Gladstone and through the reef.

QUESTION: The crew made a number of changes just prior to the impact of the vessel on Douglas Shoal. If those changes hadn't have been made, would it have been a much worse grounding? Would we have seen…

MARTIN DOLAN: I'm happy to be guided by my colleagues on the detail, but certainly our assessment is that the interventions were too late and so there wasn't - it didn't make much difference. It might have slowed the vessel slightly, turned it, but it was past the point of no return; this was going to happen anyway.

QUESTION: In other investigations that you've done, do you have anything to indicate that these issues of fatigue and navigation could be like systemic problems in cargo carriers?

MARTIN DOLAN: We have enough evidence - and this is not just about cargo carriers, this is across the transport industry and a whole range of investigations we've done - fatigue remains a key risk in all transport sectors and needs to be carefully managed.

If there are no more questions…

QUESTION: The reef tracking system, how does that work? Is it the radar system on land, or is it transponders on the ship that report their position?

MARTIN DOLAN: It's a combination. So the position of the ship is essentially established by equipment on the ship and shore-based equipment, and there's effectively a control room.

So if you like, it's a maritime equivalent of air traffic control, except it's more an advisory than a controlling system. It's - to say this is where you appear to be going, to get clarification. So it's an intervention to give information about a potential problem.

Okay, well, thank you very much for coming and if you have any further queries, we'd be happy to deal with them. Thank you very much.

* * End * *

Transcript produced by Media Monitors


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