MARINE SAFETY INVESTIGATION

REPORT 168

Independent investigation into the contact bythe Russian flag container ship

with the navigational beacon ‘E5’in Moreton Bay, Queensland on 21 April 2001

Maksim Mikhaylov

Ind

epen

den

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ation

into

the co

ntact b

y the R

ussian

flag

con

tainer sh

ip M

aksim M

ikhaylo

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ith th

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ation

al beaco

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5’ in M

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ay, Qu

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n 21 A

pril 2001

ISS

N 1447-087X

ISB

N 0 642 20045 9

Maksim M. 07 .2002

Department of Transport and Regional Services

Australian Transport Safety Bureau

Navigation Act 1912

Navigation (Marine Casualty) Regulations

investigation into the contact by the Russian flag container shipMaksim Mikhaylov

with the navigational beacon ‘E5’

in Moreton Bay

on 21 April 2001

Report No 168

July 2002

ISSN 1447-087XISBN 0 642 20045 9

Investigations into marine casualties occurring within the Commonwealth’s jurisdiction are conductedunder the provisions of the Navigation (Marine Casualty) Regulations, made pursuant to subsections425 (1) (ea) and 425 (1AAA) of the Navigation Act 1912. The Regulations provide discretionarypowers to the Inspector to investigate incidents as defined by the Regulations. Where an investigationis undertaken, the Inspector must submit a report to the Executive Director of the Australian TransportSafety Bureau (ATSB).

It is ATSB policy to publish such reports in full as an educational tool to increase awareness of thecauses of marine incidents so as to improve safety at sea and enhance the protection of the marineenviroment.

To increase the value of the safety material presented in this report, readers are encouraged to copy orreprint the material, in part or in whole, for further distribution, but should acknowledge the source.Additional copies of the report can be downloaded from the Bureau’s website or obtained from:

Marine Incident UnitAustralian Transport Safety BureauPO Box 967Civic Square 2608 ACT

Phone: 02 6274 64781800 621372

Fax: 02 6274 6699Email: marine@atsb.gov.auInternet address: www.atsb.gov.au

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CONTENTS

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Sources of information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Acknowledgment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Narrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Maksim Mikhaylov . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Brisbane Marine Pilots . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

The pilot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

The incident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

The pilot’s account . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

The ship’s account . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

Contact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Comment and analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Charting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

The turn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Inconsistencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

Performance and fatigue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Drugs and alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

Submissions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

Maksim Mikhaylov . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

Figures

1. Maksim Mikhaylov . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .iv

2. Wheelhouse from port side . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

3. Replay recorded track of Maksim Mikhaylov . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

4. Course recorder Maksim Mikhaylov . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

5. Pilot’s work hours showing sleep credit/deficit analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

6. Output graph from FAID 330E program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

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FIGU

RE 1

:M

aksi

m M

ikha

ylov

SummaryAt about 2330 on 20 April 2001, a licensed pilotboarded the Russian flag container ship MaksimMikhaylov in the port of Brisbane. The pilotexchanged the necessary pilotage informationwith the master. He then set up his electroniccharting system (ECS) and differential globalpositioning system (DGPS) display on a bridgefront window sill to the port side of the centreline in the wheelhouse. The vessel sailed fromFisherman Islands container berth at 0015 on 21April.

The vessel cleared the berth without incident.The pilot noticed at this stage that, as the tugstook minimum weight on their lines, the vesselheeled 3° or 4° indicating that the ship hadreduced residual stability, that is the shipappeared to be ‘tender’. Once established in theBar Cutting, the pilot requested that the ship’sspeed should be increased to full sea speed forthe outward passage via East Channel. At aboutthis time, the second mate took over as officerof the watch and a new helmsman took over thesteering. The master remained on the bridge,mostly on the starboard bridge wing. The nightwas fine and clear with excellent visibility, there

was little wind and a calm sea. The tide was onthe last of the ebb.

Clear of the Bar Cutting, the pilot ordered analteration of course to 060° true. Ahead, thebeacons marking East Channel could clearly beseen. The pilot alternated between the radar andhis ECS display. The second mate fixed theship’s position at five minute intervals and themaster remained on the starboard bridge wing.The helmsman steered a straight course anddemonstrated that he understood helm orders.

At about 0114, the pilot ordered five degrees ofport rudder to enter the East Channel. The ship’sswing started to accelerate and the rudder wasordered to amidships. Maksim Mikhaylov

contacted Beacon E5 at about 0115:30.

Other than superficial paint damage Maksim

Mikhaylov sustained no damage, but the beaconsuffered substantial damage. The pilot reportedthe incident at 0125.

The ship continued on passage, anchoring offPoint Cartwright where the master and pilotprovided a statement to an official ofQueensland Transport and a preliminaryassessment of any damage to the ship was made.

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Sources ofInformationThe master and crew of Maksim Mikhaylov.

The pilot and Brisbane Marine Pilots Pty Ltd

Queensland Transport.

AcknowledgmentThe Inspector is grateful to Interdynamics PtyLtd (www.interdynamics.com) for the computerprogram, FAID 330E, which was used duringthe analysis of the fatigue factors.

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Narrative

Maksim MikhaylovMaksim Mikhaylov is a Russian flag containervessel. The ship was built in 1979. It is 198.9m in length, has a beam of 25.4 m and amoulded depth of 17.45 m, with seven cellularholds which, together with on-deck stowage,gives a capacity of 1254 TEU (twenty-footequivalent units). The ship is powered by a12 799 kW Sulzer engine giving a service speedof 20 knots.

The bridge is 149.9 m from the bow. It isequipped with a range of navigational aidsincluding three radars, one of Russianmanufacture and two Decca ARPA radars (10and 3 cm). There are also two GPS receivers,one Navtrax and one Shipmate model. The shiphas only one gyro repeater in the wheelhouse(other than those in the radars), which is in thesteering stand. It has a single, deckheadmounted, centreline rudder angle repeater whichhas three displays within it. One display facesthe helmsman and the other two face the portand starboard sides. All this equipment wasoperating normally.

In addition to the master, the ship’s crewconsisted of 22 Russian nationals. All thewatchkeeping officers were appropriatelyqualified.

The master was a man of considerableexperience having commanded container shipsand a passenger cruise ship, including voyageson the Australian coast. He estimated that hewould have made as many as eighty voyages toBrisbane.

Brisbane Marine PilotsBrisbane Marine Pilots Pty Ltd is the pilotservice provider company for the Port ofBrisbane. This company’s pilots operate on a

cycle of sixteen days with ten days on dutyfollowed by six days off.

To minimise the risk of pilots being affected byfatigue, Brisbane Marine Pilots operate a riskmonitoring system based on a fatigue indexprogram developed by the Centre for SleepResearch, University of South Australia. Thisdocument is supplemented by ‘Pilot JobAllocation’ guidelines, which are used by thepilot operations coordinators when assigningpilots to ships. These guidelines suggest aminimum period of eight hours between ships(one hour each way for travel plus a six hourbreak).

The number of pilots on duty rosters is based onnormal traffic patterns, supported by a fatiguemanagement policy. Pilots’ duty hours areassessed including the hours involved in travelto or from duty and the hours of pilotage. Theseduty hours are entered into a fatigue computerprogram which returns a ‘fatigue index score’for each pilot at any time. The pilotage companyhas set an index score of 80 as a warning toitself. Should pilots get above this score they areconsidered to be entering a risk zone for fatigue.

As a part of their normal shipboard operatingprocedures, pilots carry a portable electroniccharting system (ECS) on a laptop computer,which also contains a differential globalpositioning system receiver. When pilots werefirst issued with these units, a number of routeswere already entered into the program. Thispilot had changed these to reflect the routes henormally used, others left them unchanged andused the routes in the program as only a roughcheck against the ship’s actual track. The ship’sreal time position is plotted automatically everyten seconds, together with the course made goodand the ship’s speed, all of which is stored in amemory file.

The pilotThe pilot assigned to Maksim Mikhaylov on the20 April 2001 joined Brisbane Marine Pilots inJune 1999, gaining his initial licence on

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5 August 1999. He holds a valid certificate asMaster Class 1. He has had extensive experienceat sea as well as in the Brisbane River as a tugmaster since 1991 and in passages throughMoreton Bay to Point Cartwright.

Earlier on 20 April 2001, before joining MaksimMikhaylov to conduct the ship to sea, he hadundertaken an inward pilotage passage leavinghome at 0620 but not actually boarding the shipuntil 1027 for the inward passage. The pilotageitself then took about four and a half hours,before he returned home at 1615 that day. Onarrival at home he called the pilot operationscentre and was told that he was to pilot the out-bound Maksim Mikhaylov, sailing at 2300 fromFisherman Islands. He rested for an hour beforea meal. He went to bed some time between 1930and 2000. At about 2030 the pilot’s wife took aphone call from the pilot company informingher that the sailing had been delayed untilmidnight. Unaware of this message, the pilot gotup as scheduled at 2130 to be told of thedelayed sailing. He went back to bed almostimmediately and slept until 2230. At 2300 heleft home and boarded Maksim Mikhaylov at2330.

The incidentMaksim Mikhaylov arrived at berth number 6,Fisherman Islands on the morning of 20 April2001, with a scheduled sailing time of 2300 thatevening. The ship worked containers throughoutthe day. Sailing was postponed by one hour tomidnight on 20 April.

At 2330 the pilot arrived on board MaksimMikhaylov. He then briefed the master on theunberthing manoeuvre and the passage from theberth to the pilot ground off Point Cartwright.The plan, with the ship at a draught of 8.2 mforward and 8.5 m aft, was to depart via theEast Channel. Predicted high water at BrisbaneBar was at 1952 at a height of 1.98 m and lowwater was predicted at 0158 at a height of 0.56 m above datum.

On board Maksim Mikhaylov, after theinformation exchange with the master, the pilot

rigged the DGPS aerial and set up his laptop,with its electronic charting system on the portside of the wheelhouse, about 8 m from the centre line. He entered theposition of the aerial relative to the bow, sternand sides of the ship. His preferred outwardpassage plan had already been set on theelectronic chart.

The master provided him with a pilot cardproviding some details of the ship’smanoeuvring characteristics. This includedinformation that it took 60 minutes to increasefrom manoeuvring full ahead to full sea speedof 16 knots. The deck was stacked predomi-nantly with one tier only of containers andforward vision was not impaired.

At 0010 the ship commenced letting go itsmooring lines. The tugs lifted MaksimMikhaylov clear of the berth under the pilot’sdirection and the ship started its outwardpassage. The pilot noticed at this time that, asthe tugs took minimum weight on their lines,the vessel heeled 3° or 4° indicating that theship had reduced residual stability, that is, it wasconsidered to be ‘tender’. He commented onthis to the attending tugs. The master, the mateand the radio officer were on the bridge togetherwith a seaman at the wheel. As the shiptransited the Inner Bar Cutting, the pilot askedfor full sea speed. At about this time the secondmate relieved the mate and the helmsman wasrelieved by another seaman.

The ship cleared the entrance beacon at 0044,steering 032°(T). Five minutes later, at 0049, thepilot ordered an alteration of course to 060°(T)towards the entrance to the East Channel. Therewas no gyro compass repeater visible to thepilot and the helmsman called the heading everyfive degrees to the heading of 060°(T) duringthis alteration.

The tide was in the last stage of the ebb. Theweather was fine with good visibility and therewas a calm to slight sea.

The second mate fixed the ship’s positions atfive-minute intervals using the radar and ship’s

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GPS. Soon after clearing the Entrance Beacons,the second mate offered the pilot use of thecoffee making facilities, which the pilotaccepted. He was also offered the pilot chair tosit in, which the pilot declined. The second matestated that when offering the pilot a cup ofcoffee and the pilot chair to sit in, the pilot hadindicated that he was tired and declined the useof the chair. The pilot had no recall of such aconversation and stated that it was his practicenever to sit while conducting a pilotage. Noother person heard this alleged conversation.

The helmsman saw the pilot and second mate inoccasional conversation but was not aware ofwhat they were talking about. The pilot, for themost part, remained at the port side of thewheelhouse close to his ECS display and theport radar. The master remained mostly on thestarboard bridge wing, but occasionally enteredthe wheelhouse briefly.

At interview the pilot stated that he could notsee the rudder indicator until he had movedfrom his position to about 5 m to port of thecentre line. This rudder angle indicator was of atype that is mounted on the deckhead. It is ofcircular construction showing the rudder angleon the port and starboard sides of thewheelhouse and also to a person, such as thehelmsman, standing on or near the centre line.

As the second mate was plotting the ship’sposition at 0115, the pilot ordered 5° portrudder to bring the ship into the East Channel.From this time the accounts of the followingfive minutes differ to a material degree.

The pilot’s accountThe vessel was approaching beacon E5 at thistime. The pilot recalled that the beacon wasabout 3 to 4 points (33-45°) on the port bow andhe now gave the order to apply 5° port rudder.As the vessel turned, the helmsman called theheading at five-degree intervals, as he had donewhen altering course previously off the EntranceBeacons. At a heading of 050°(T) the pilot wasconcerned that the ship was turning too rapidly

and ordered the rudder amidships, an order thatwas repeated by the helmsman. When thehelmsman confirmed that the wheel wasamidships the pilot ordered 10° of starboardrudder to check the ship’s rate of turn. Thisorder was also repeated by the helmsman.

However, the rate of turn did not slow and, ifanything, increased. The pilot moved towardsthe helmsman’s position and ordered 20°starboard helm. As he moved towards the centreline the pilot saw that the rudder indicator wasindicating 20° of port rudder. He immediatelytold the helmsman that the rudder was thewrong way and to go hard to starboard.

At this point the master came rapidly towardsthe centre of the wheelhouse from the bridgewing saying he was unhappy about the rate ofturn to port. The pilot told the master that thehelmsman had put the wheel the wrong way andthat the rudder should be put hard to starboard.At this point the master spoke in Russian to thehelmsman. The rudder was put hard to starboardand, with beacon E5 about one ship’s lengthahead, the turn to port stopped. However, thiswas not in time to prevent the ship hitting thebeacon.

The master went to the port bridge wing andwatched the beacon pass down the port side. Asthe vessel turned back into the channel the pilotordered the ship to steady on a heading in thevicinity of 020°(T) or 025°(T), before settingcourse on 015°(T) and continuing the pilotage.

The ship’s accountAt 0115 the master was on the starboard bridgewing and the second mate and helmsman wereinside the wheelhouse. The master stated thathis habit was to spend most of his time on thebridge wing and to come to the wheelhouse justbefore any alteration of course. He was able tomonitor both the engine revolutions and therudder angle from a tachometer and rudderangle indicator mounted above the forward sidewheelhouse window, facing outward onto thebridge wing.

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The second mate was fixing the ship’s positionat five-minute intervals, moving from the radarto the ship’s GPS display behind the chartconsole. At 0115 he had just taken the ship’sposition as 048°(T) x 0.82 miles to beacon E5.He could also clearly see beacon E5.

The helmsman was steering a course of 060°(T).He could clearly see beacons E5 and E4 almostin line, fine to port. He recalled that the pilotordered 5° of port rudder with beacon E5 stillseen over the outboard foremost container, anangle of about 5°. He turned the wheel to apply5° port rudder and called the heading as itpassed 055° and 050°.

The master had not anticipated that the coursewould be altered at this time and was concernedthat the ship was turning too soon and toorapidly. He entered the wheelhouse and, simulta-neously with the pilot, ordered starboard rudder.He then went quickly to the chart table to see ifit was possible, at their particular draught, toleave beacon E5 to starboard. It was not.

The ship’s staff on the bridge stated that thepilot seemed frozen for a few moments anddisorientated. The pilot ordered port rudder butthis was countermanded by the master. Fromthis time the helmsman disregarded the pilot’shelm orders and obeyed only the master’sinstructions.

The second mate plotted a position at 0118,putting the ship alongside beacon E5.

ContactBased on the timing taken from the pilot’selectronic chart, initial contact was madebetween beacon E5 and the break of theforecastle at 0115:30 at a speed of 14.5 knots on a heading of 038° (from thecourse recorder trace). The ECS does not recordship’s heading information but it showed acourse made good at this time of 000°. The ship

cleared the beacon, which passed down theship’s side, clearing the ship some 26 secondslater.

Following the contact with the beacon, MaksimMikhaylov regained the mid-channel and thesituation returned to normal. The master orderedthe second mate to check for damage inside thehull. Another seaman relieved the helmsman.

At 0125 the pilot notified Brisbane Port Controlof the incident, reporting that the ship hadcollided with the beacon and that the light onthe beacon was extinguished. The masterreported the incident to his company contactsand the ship’s Brisbane agent.

At 0225 the pilot reported that ‘all tanks havebeen sounded and appear to be sound, the vesselwill be going to Point Cartwright for furtherinspection.’

The ship continued on, anchoring off PointCartwright at 0345. An inspection of the shipshowed two areas of contact and hull paint damageon the port side. A 300 mm wide strip extendedaft from the ship’s name on the bow for about30 m. A further strip of paint was missing fromthe hull in way of the superstructure towards thestern. Further checks on the fuel and ballasttanks and void spaces were carried out. Otherthan the stripped paint no other damage wasdetected.

E5 beacon had been damaged by the contact.The beacon was at an angle of about 35° fromthe upright and its light was extinguished.

At 0450 the pilot disembarked from MaksimMikhaylov. At 0550 a director of BrisbaneMarine Pilots Pty Ltd boarded the containership, at the request of the harbour master, to talkto the master and conduct an assessment of theincident. The senior pilot disembarked at about0735 and the ship resumed its passage forManila.

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FIGURE 2:Wheelhouse from port side

Central rudder indicator

Position of pilot’s GPS display

Port radar

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FIGU

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Comment andanalysis

EvidenceInterviews were conducted with the master,second mate and helmsman on 23 May 2001.Ship’s documents including photocopies of theRussian chart of Moreton Bay (Chart 56334,equivalent to Aus 236), the pilot card,procedures and the course recorder trace wereprovided by the ship and Queensland Transport.

An interview with the pilot was conducted on 7 May 2001. The pilot provided the investigatorswith a copy of his ECS file for the night of the20/21 April. This provided an accurate real-timedisplay of the track and course made good byMaksim Mikhaylov from the berth to sea. A pilotis unable to alter or access the files recordingthe ship’s track. Another file was also providedwhich overlaid the pilot’s voyage plan on theabove records.

The ship’s course recorder trace was notsynchronised with the bridge clocks. There wasa notation on the course recorder chart roll‘0000 210401’ with a signature marked againstthe trace just about the time that the traceindicates that the ship’s head started to alter.This is not consistent with known times ofalteration of course. The course recorder chartis 4 hours 381⁄2 minutes fast of the time shownon the pilot’s ECS and it was reading one degreelow.

In trying to reconcile the two accounts of theincident from about 0110 onwards, the ship’scharted positions and course recorder trace werecompared with the pilot’s ECS plotter. Thecorrections between the datum for the chart(AHD66) and the pilot’s electronic chart datum(WGS84) were applied.

The ship’s charted positions at 0110 and 0115were about 0.8 of a mile (1482 m) astern of the0110 and 0115 positions taken from the pilot’sECS plot. At 0115 the ship’s charted positionwas 1518 m from beacon E5. The evidence fromthe pilot’s ECS plot is that the ship started toalter course for East Channel at 0114, 685 mfrom Beacon E5. To equate this to the ship’stime keeping, given a speed of 16.6 knots, thecourse alteration therefore started about 1 minute 36 seconds after 0115 ship’s time.Comparing the positions plotted by the secondmate on the ship’s paper chart with theequivalent positions from the ECS, including thetime of contact with the beacon, the ship’s timeappears to be in advance of the pilot’s time byabout 21⁄2 to 3 minutes.

For convenience the ship’s times have beenadjusted to the time shown on the pilot’s ECS.

ChartingAfter the incident the master took informationfrom the pilot’s plot and compared it with theship’s own charted position. The pilot’s positionswere based on World Geodetic Survey 84 (WGS84) datum (from GPS), while the Russianchart was based on Australian HydrographicDatum 66 (AHD66). Any direct transfer ofpositions, without correction, would have showna position north and east of the ship’s actualposition relative to the charted position ofbeacon E5. This variation would have beencompounded by the three minute difference intime.

The turnThe electronic chart record shows that the shipwas consistently 370 m to the north of thepilot’s planned track. This was not due to anyset; there was little tidal effect during thepassage across Moreton Bay. The pilot statedthat he was aware that he was to the north of hisproposed charted track but, given the shippingsituation (no traffic in the area), the calmweather and clear night, he was not concerned.

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He also felt that he didn’t need to make anyalteration to his plan for the ship’s apparenttenderness. Even though this condition was notunusual for a container ship, he was aware thatthis tenderness would affect the ship’s turningcharacteristics. His intention was to alter coursewhen beacon E5 was about 45° on the bow at adistance of about 4 cables.

The second mate had also drawn a course lineon the ship’s paper chart, across Moreton Bay.When corrected for chart datum the ship was atall times to the south of the ship’s course line.These differences arose because the ship and thepilot were using slightly different waypoints forthe turn position at beacon E5.

There is agreement by all parties that the initialhelm order was for 5° port rudder. The ship’spilot card shows that to maintain a steady coursethe ship carried 2° starboard rudder. The neteffect of the initial rudder angle was 7° to port.The master also stated that the ship turned at aquicker rate to port than starboard.

Even when dimmed, the rudder angle appearedeasy to see on the rudder angle indicator.

The pilot stated that he planned to ease the shipround the beacon and, when the ship started toturn, he was not concerned initially and orderedamidships. The master stated that he hadcountermanded a pilot’s order of 15° port helm.Which version, if either, is correct, cannot bedetermined with any certainty. There are anumber of inconsistencies in the accounts.

InconsistenciesThere is an inconsistency between the twoaccounts as to the position at which the pilotinitiated the alteration of course to enter EastChannel.

The alteration of course from the line of theEntrance Channel leading lights was started at0048 (about 0527 by course recorder). The shipaltered its heading through some 29° and settledon a course of 060°(T) at 0051. The shipremained on this course for 231⁄2 minutes, asconfirmed by both the course recorder and the

pilot’s ECS plot. At 0114, with beacon E5bearing 021.2° on the port bow at 0.37 miles,the ship started to alter course to enter the EastChannel. The ship had effectively followed thepilot’s planned track even though the ship wasoffset to the north. The pilot did not initiate thealteration of course with beacon E5 at 5° on theport bow, as recalled by the ship’s personnel.The evidence available supports the pilot’saccount in relation to the initial alterationposition.

There is also an inconsistency in the master’sdescription of the turn. The master stated thathis practice was to enter the wheelhouse tomonitor alterations of course, but on thisoccasion the pilot altered course prematurely.The master did not anticipate the alteration foranother two minutes. The evidence, based on theship’s position from the pilot’s electronic chart,is that, had the master waited a further twominutes, Maksim Mikhaylov would have beenmore than midway across East Channel and only185 m from beacon E4.

The 0115 position (ship’s time), as plotted bythe second mate, was 0.82 miles (1518 m) frombeacon E5. At 16.6 knots the ship would havetaken fractionally less than 3 minutes to coverthe distance and contact beacon E5. However,the pilot’s ECS shows that from the time theship started to turn to port off beacon E5 untilthe initial contact, about 75 seconds hadelapsed.

In an attempt to reconcile the differing accountsof the ship’s staff and the pilot in relation to therudder orders, the course recorder trace from0114 to 0120 was enlarged and examined. Thereis agreement that the initial order was for 5°port rudder.

The course recorder indicates that the shipaltered its heading through 60 degrees in 21⁄2minutes, reaching a heading of 000°(T) at0116:30. (The course recorder shows a verybrief excursion into the 270°–360° quadrant.)The ship’s heading then returned to a heading ofabout 025°(T) at 0118, before steadying on acourse of 020° at 0119:30.

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The rate of turn was calculated from the slopeangle of the recorder trace. The results areapproximate, as there is inevitably some penvibration. There appear to be four distinctcomponents to the curve:

• for the first minute (0114 to 0115) the rate ofturn was 21°/min;

• for the next minute (0115 to 0116) the rate ofturn increased to 33°/min;

• for the next 30 seconds (0116 to 0116:30)the rate slowed to about 10°/min;

• then returning to a heading of 025°(T) at arate of 15°/min.

From analysis of the slope of the courserecorder trace there is no indication that the shipsignificantly slowed its rate of change ofheading over the first two minutes of the turninto the East Channel. This suggests that therewas no early intervention with counter rudder tosupport the ship’s account. However, given thelimitations of the course recorder trace, theanalysis cannot be taken as positive support forthe pilot’s account.

What is plain, however, is that bridgemanagement and the checking of both the pilot’sorders and the helmsman’s response wereabsent. There was no consistent third partymonitoring of the agreed passage plan.

For the pilot, this was exacerbated by the factthat the only gyro repeater in the wheelhouse,other than those on the radar displays, was onthe steering column. When the ship was turning,the pilot could not monitor the turn at hispreferred conning position. He relied on thehelmsman to relay the ship’s heading.

The helmsman was an experienced seaman andhighly rated by the master. It was clear atinterview that he had no difficulty inunderstanding helm orders or basic marineEnglish. The pilot reported that he steered well.

Performance and fatigue The ship did not keep a record of actual hoursworked, but only a record of who kept whichbridge watch. As a result of this, a full analysisof the fatigue levels for the ship’s master andcrew was not possible. Given the long hoursand the times of working experienced by themaster and crew of Maksim Mikhaylov from thetime of approaching the pilotage early on 20 April, through to the early morning of 21April, some decrement in performance wasalmost certainly present in some, if not all, theship’s bridge personnel.

The Port of Brisbane experienced 25 shipmovements on 20 April, including 11 inwardand 10 outward passages. On 21 April the totalwas 21 movements, 18 of which were either

FIGURE 4:Course recorder trace Maksim Mikhaylov

00151⁄2 contact

A/c 0014 Bn.E5brg 021°X 0.37

060°(T)

031°(T) fromEntrancechannel

inward or outward passages. This necessitated amore intense program of duty for some pilots.

The pilot assigned to Maksim Mikhaylov hadslept from about 2100 on 19 April to 0500 onthe 20 April and left home at 0620 for the pilotstation at Mooloolaba. He arrived home at 1615the same day having piloted an inward boundtanker.

He then rang the office at 1620 and wasassigned, for an anticipated period of six hours,to the Maksim Mikhaylov, sailing at 2300. Forthis job he required about 30 minutes travellingtime so he would have a maximum rest periodof about 6 hours. While the pilot was asleep thisperiod was extended by one hour. The pilotwoke briefly in line with his original schedulebefore sleeping again for less than one hour.

A number of factors point to a possiblesignificant level of fatigue on the part of thepilot, leading to a decrement in performance andhence further examination of the pilot’s fatiguestatus:

• he went to sleep quickly when he went to bedat 2000 on 20 April and having beenwakened and got out of bed at 2130, he wentstraight back to sleep;

• evidence from the second mate indicated thatthe pilot expressed a degree of tiredness (thiswas refuted by the pilot);

• the fact that the wheelhouse rudder indicatordid not register with the pilot when the turninto East Channel was established at about0115, or that he could not see it clearly.

• the ship’s staff on the bridge stated that thepilot seemed frozen for a few moments anddisorientated.

• the pilot allowed the vessel to continue totrack to the north of his chosen route eventhough there was no traffic in the area andthis direction would have resulted in the need

for a quicker turn or less distance (and time)to steady the heading after arriving at thenext course. The pilot was aware that the shipwas tender and so he would need to takemore care during shiphandling.

To assess the pilot’s possible exposure to fatiguethe simple test of ‘sleep credit/deficit’ wasapplied to the pilot’s work hours. The systemcredits sleep hours with a credit of two pointsfor every hour of sleep and one point debit forevery hour awake. The system makes noallowance for physical or mental effort or forcircadian rhythms. A negative score onlyindicates that the work hours warrant greaterexamination.

The pilot had returned from a period of leave,starting the ten day roster on 12 April.Examination of the roster hours show that onthe morning of 14 April the pilot started the daywith a full credit of 16 points.

Except for two minor incursions into thenegative, his score remained positive until 18 April, after which the scores were generallynegative. At the time of the contact with beaconE5 the pilot’s work schedule indicated that hewas some 7 points into the negative side of theequation.

To more thoroughly examine the pilot’s possibleexposure to fatigue, his program from 12 Aprilwas analysed using the Interdynamics Pty Ltd,FAID 330E fatigue program. Two scenarioswere modelled, one using the total hours awakethroughout his duty period, and the second usingthe most conservative estimate of hours actuallyinvolved in travel to and from duty and hisperiods of actual pilotage. The two sets offigures and graphs provided a ‘high’ and ‘low’fatigue estimate.

The pilot company’s computer programgenerated a fatigue index score of 75 at 0115 on21 April. This was nearly the same score asgenerated by the FAID 330E fatigue program,based on the conservative, ‘low’ duty hourestimates. Using the total hours awake, the

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FAID 330E fatigue program gave a fatigueindex score of 120 at 0115. This reflects adegree of subjectivity in assessing the inputhours.

Fatigue programs are useful tools anddemonstrate a responsible and professionalapproach to safety management. However, inmarginal cases they can only be taken as a guideto fatigue factors. Neither the FAID 330Efatigue program, or its earlier version currentlyused by the Brisbane Pilots, make allowance formode specific environmental factors, such asnoise, motion, vibration and light.

Figure 6 is a copy of the output graph from theFAID 330E program. This shows the index scoreat any time and indicates the effects of circadianrhythms as well as the biological limits ofrecovery as time on duty progresses.

While the pilot was operating within the pilotcompany’s guidelines, having analysed thepilot’s routine over the preceding days andassessed the pilot’s actions leading up to thecontact with beacon E5, the Inspector issatisfied that some level of fatigue contributedto the incident.

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FIGURE 5:Pilot’s work hours showing sleep credit/deficit analysis

16

12

8

4

0

4

8

12

14 15 16 17 18 19 20 21

1200 1200 1200 1200 1200 1200 1200 12000000 0000 0000 0000 0000 0000 0000 0000

Positive index score

Indicating possiblefatigue

Negative index score

Contact

Disembarked

Drugs and alcoholThe pilot was not on any medication. There isno evidence that any person involved in thisincident was affected by either alcohol, drugs ormedication.

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FIGURE 6:Output graph from FAID 330E program

ConclusionsThese conclusions identify the different factorscontributing to the incident and should not beread as apportioning blame or liability to anyparticular individual or organisation.

1. After the initial turn was established, the turnto port was maintained by mistakenapplication of port rudder as a result of eitherthe pilot giving the wrong order, or thehelmsman applying the wheel to port ratherthan starboard. The rate of turn wasexacerbated by the ship’s low level of reservestability.

2. The lack of proper monitoring of either thepilot or the helmsman by the master andofficer of the watch contributed to thecontact with beacon E5.

3. The lack of proper monitoring of thehelmsman by the pilot, whilst he was givingcommands and they were being executed,contributed to the contact with beacon E5.

4. There was a demonstrated lack of BridgeResource Management.

- There was a lack of communicationbetween the master and pilot. There wasalso a lack of oversight of the pilot by themaster during the passage .

- There was no ‘shared mental model’ withdefined limits which could be challengedif exceeded. The ship followed closelyneither the pilot’s nor the ship’s plannedroute. The ship was on the ‘wrong’ side ofthe pilot’s proposed route and this was notchallenged by the Officer of the Watch.

5. The pilot was affected by a measurabledegree of fatigue. The volume of shipping atthat time put an extra demand on pilotageservices, resulting in shorter than normal

breaks between duty periods. The pilot was atthe end of his rostered-on period.

Although not contributing factors it is alsoconsidered that:

- The pilot gave the order to turn from theheading of about 060° to enter EastChannel at the position he originallyplanned. The order was given neither tooearly nor too late.

- Language and a proper understanding ofthe orders given by the pilot were notcausative issues in the contact withbeacon E5.

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1. Brisbane Marine Pilots Pty Ltd review itsfatigue management procedures with a viewto setting maximum scores allowable at thecommencement of each duty including anallowance for the anticipated length of theproposed duty cycle.

2. Brisbane Marine Pilots Pty Ltd introducesome ‘fine-tuning’ to its current fatiguepolicy. An example of such fine-tuning is the‘5/12 rule’. That is, if a pilot has had lessthan 5 hours sleep in the past 24 hours, orless than 12 hours sleep in the last 48 hourspreceding the start of the shift, the pilotshould notify the line manager and undertakea more detailed risk assessment.

3. Pilots and other conning officers shouldconsider the use of hand signals tosupplement verbal commands. This couldhelp to reduce the possibility of misinterpre-tation of wheel orders during ship handlingperiods especially where languagedifficulties might be a problem.

4. Masters and pilots should review theirinformation exchange process to includeinformation of importance contained in thevessel’s hydrostatic or manoeuvring data,particularly the zig-zag test, which givespertinent information regarding the steeringability of the vessel. This is especiallyimportant where a vessel is known to havepoor handling characteristics and/or suspectmargins of dynamic stability.

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Recommendations

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SubmissionsUnder sub-regulation 16(3) of the Navigation(Marine Casualty) Regulations, if a report, orpart of a report, relates to a person’s affairs to amaterial extent, the Inspector must, if it isreasonable to do so, give that person a copy ofthe report or the relevant part of the report.Sub-regulation 16(4) provides that such a personmay provide written comments or informationrelating to the report.

The final draft of the report, or relevant partsthereof, was sent to the following:

The master Maksim Mikhaylov

The second mate Maksim Mikhaylov

Far Eastern Shipping Company

Brisbane Marine Pilots

The pilot of Maksim Mikhaylov

Australian Maritime Safety Authority

No submissions were received from the master,second mate or Far Eastern Shipping Company.

Submissions were received from BrisbaneMarine Pilots and the pilot of MaksimMikhaylov.

Where appropriate, the text has been changed tocorrect the draft or reflect the submission.

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Maksim MikhaylovIMO Number 7614379

Port of Registry Vladivostok

Flag Russian

Classification Society Russian Register

Ship Type Cellular Container

Builder Warnow Werft East Germany

Year Built 1979

Owner Far Eastern Shipping Company

Gross Tonnage 22 369

Net Tonnage 12 882

Deadweight Summer 23 216 Tonnes

Length overall 198.90 m

Breadth (moulded) 25.40 m

Depth (moulded) 14.7 m

Summer Draught 9.202 m

Engine Sulzer 6 RND90

Power 12 799 kW

Crew 23 (Russian)

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