Shen Neng grounding on Douglas Shoal

People

Environment

Equipment

Procedures

Organisation

Third Parties

Chief Mate 1, p.8

The Shen Neng 1 was equipped with electronic navigation aids 1, p. 2

Great Barrier Reef (GBR)

Great Barrier Reef and Torres Strait Vessel Traffic Service (REEFVTS) 1, p. 4

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From 30 March to 1 April the chief mate spent an extra 3 hours each evening after his watch checking cargo and stability calculations in comparison with the ship's cargo computer calculations 1, p. 8

The chief mate had 20 years experience at sea 1, p.2

3 April 2010 at 0100 The chief mate left the second mate in charge and returned to his cabin and slept until 0300. 1, p.9

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The chief mate had 11 years experience supervising navigation watches 1, p.2

The chief mate received Chinese qualifications as a chief mate in 2007 and was promoted to the rank of chief mate afterwards 1, p.2

The chief mate joined the Shen Neng 1 crew only one month before the incident 1, p.2

The chief mate worked for the Shen Neng's managers since 2008 1, p.2

This was the chief mates first visit to Gladstone (same as the ship's master) 1, p.2

2 April 2010 at 0300 the chief mate supervised the crew weighing anchor from the forecastle. 1, p.8

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At 0330, the chief mate went to the accommodation area to get prepared for his watch 1, p.8

At approximately 0400, the chief mate relieved the second mate on the bridge and began his watch 1, p.8

0720 the ship was made all fast in Gladstone port and the chief mate returned from the forecastle to the ship’s office and prepared for cargo loading. 1, p.8

0600 the chief mate went to the forecastle

0820 the chief mate began supervising the loading of the ship

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The ATSB investigation found that the grounding occurred because the chief mate did not alter the ship’s course at the designated course alteration position 1, p.xii

The chief mate remained busy in the cargo control room the remainder of the day and into the evening of 2 April 2010. 1, p.8

0300 The chief mate was called when the cargo surveyor boarded the ship. 1, p. 9

0540 the loading was completed

0610 the chief mate and cargo surveyor worked on the cargo calculations and paperwork. 1, p.9

0730 the final figures were completed and the chief mate continued checking the ships stability calculations and cargo figures. 1, p.9

0900 the chief mate went to breakfast. 1, p.9

0930 the chief mate returned to complete the paperwork 1, p.9

1035 the chief mate returned to the forecastle for the ships departure. 1, p.9

1054 the ship departed Gladstone with the chief mate at the forecastle. 1, p.9

1115 the mates forward and aft were stood down. 1, p.9

1220 the chief mate finished lunch and returned to his cabin set his alarm for his 1530 watch and lay down on his bunk. 1, p.9

1530 the chief mate was awoken by his alarm he had only slept for 30 minutes. 1, p. 12

1550 the chief mate returned to the bridge checked the log book and chart where the second mated showed him the course change to 020 degrees. The second mate also showed the chief mate the next way point and pointed out that the amended way points had not been entered into the GPS unit. The chief mate acknowledged all of the information provided by the second mate.1 p.12

1600 the watch was handed over to the chief mate by the second mate after the ship's position was fixed. 1, p. 12

1600 the chief mated made note of North West Island and other potential dangers in the area. After looking at the chart the chief mate estimated the ship would arrive at the next waypoint at 1700 and decided to fix the ship's position at 1630 leaving chart Aus 819 on the chart table. 1, p.12

The chief mate was feeling tired and decided to take a position on the starboard side where he could see out the windows and view the ARPA Radar display. 1, p. 12

1630 the chief engineer came to the bridge and interrupted the chief mate's planned time to fix the ship's position. 1, p. 13

1635 The chief mate decided to fix the ships position at 1700. 1, p. 13

1700 the chief mate fixed the ship's position and had to retrieve an additional chat (Aus 819) to fix the position. 1, p.14

At approximately 1702 the chief mate realised that the ship was entering the boundary of the 'no go zone' in proximity to Douglas Shoal. 1, p.14

At approximately 1703 the chief mate immediately ordered the lookout to engage manual steering and alter the course to starboard. 1, p. 14

1705 the Shen Neng 1 had grounded on Douglas Shoal at a position of 23º 06.0’S 151º 39.6’E, close to a charted depth of 10.7 m. 1, p.14

The GBR is a Marine Park and World Heritage area. 1, p. 2

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GBR has been declared a Particularly Sensitive Sea Area (PSSA) by the International Maritime Organisation. 1, p. 2

Under World Heritage Convention and with PSSA status Australia is required and has an obligation to provide protection for the GBR and wildlife in the Marine Park. 1, p. 2

The GBR sustains both commercial and recreational activities worth over 5 billion dollars per year. 1 p.2

Eleven ports operate within the GBR Marine park and account for over 11 billion in trade annually. 1, p.3

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Arrangements have been made to allow for shipping within the GBR Marine Park area which includes protecting the environment and wildlife. 1, p. 3

1991 Compulsory pilotage was implemented fro vessels travelling between Cairns and cape York. Vessels mus carry a licensed pilot through the Inner Route of the GBR. 1, p. 3

1997 a ship reporting system was introduced which required ships to report their position regularly. 1, p. 3

2004 coastal vessel traffic service (VTS) was introduced in the area north of 22 degrees south and provides information on traffic conflicts and navigation information. 1, p. 3

2004 a zoning system was implemented which allows ships to transit the reef through designated passageways. this included general use zones and designated shipping areas. 1, p. 3

The Great Barrier Reef and Torres Strait Vessel Traffic Service (REEFVTS) assists with navigational safety in designated areas. 1, p. 4

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REEFVTS is comprised of of the ship reporting system (REEFREP). 1, p.4

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Automatic Identification System (AIS) 1, p. 4

Radar 1, p.4

Automated position reporting via Inmarsat-c satellites 1, p. 4

VHF radio reporting 1, p. 4

System integration via the Traffic Information Model (TIM) 1, p. 4

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TIM utilises electronic navigational charts 1, p. 4

Ship position and track information is displayed utilising information from AIS, radar, and Inmarsat to display near real time monitoring of ships positions 1, p. 4

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Navigational assistance (information to assist onboard decisions) 1, p.4

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Ship Traffic Information (STI) 1, p. 4

Maritime safety information (MSI) 1, p. 4

TIM generated ship encounter predictions 1, p. 4

Includes navigation warnings and information 1, p. 4

Provided by VHF radio 1, p. 4

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REEFVTS provides coverage of the Torres Strait and northern GBR 1, p. 4

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Shen Neng 1 navigation bridge was equipped with navigation equipment which meets Safety of Life at Sea (SOLAS) requirements 1, p. 2

Shen Neng 1 was not equipped with any electronic navigation charts or an electronic charting and display system (ECDIS).1, p. 32

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Global maritime distress and safety system (GMDSS) station 1, p. 2

Two Global Positioning System (GPS) units (a Raytheon NAV398 and a Furuno GP-80) 1, p. 2

Sailor KDU1905 automatic identification system (AIS) unit 1, p. 2

Two X-band radars 1, p. 2

or gate OR

There was a miscommunication of information due to language barriers.

The chief mate did not understand the information properly due to fatigue.

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The chief mate had filled out a work record form from when he joined the ship in Korea up until 31 March 2010, in accordance with the requirements. He had not recorded any hours since 31 March. 1, p. 26

On each day since joining (with the exception of two), the chief mate had recorded only the hours he had spent on watch as the hours he worked that day 1 p. 26

It is a usual and recognised practice that, for a chief mate to properly fulfil his role as head of the deck department, he has to work additional hours outside the 4 to 8 morning and evening navigational watches while the ship is at sea or at anchor. 1, p. 26

This is particularly pertinent for a chief mate who has just joined a ship for the first time, as Shen Neng 1’s chief mate had. This is due to the degree of unfamiliarity that exists with the ship, its systems and equipment, 1, p. 27

or gate OR

It is probable that Shen Neng 1’s chief mate did not record some of the hours he worked since joining the ship so that the hours he did record were in accordance with the requirements of the SMS and STCW. 1, p. 27

By not recording all his hours worked, the chief mate, and any other crew member who might have been doing the same, was only completing the form so that an inspector (auditor or surveyor) could see that the hours were being recorded and that they were in accordance with the company’s SMS requirement. 1, p. 27

The recording of hours merely to pass an inspection is an indication that the system was not being used as a proactive means to properly manage the level of fatigue of watchkeepers. The result is a record which appears to fulfil the regulatory working and rest hours requirements but which does not properly fulfil the fatigue management intent of the STCW Convention and Code. 1, p. 27

Australian Maritime Safety Authority

'At the time of the grounding, the protections afforded by active monitoring of ships by REEFVTS were not in place in the sea area off Gladstone. [Significant safety issue]' 1, p. 42

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Although the Shen Neng 1 grounding caused damage to the coral reef on the Douglas Shoal, only a relatively
small amount of heavy fuel oil (approximately 3–4 tonnes) was spilled into the sea as a result of the incident 2, p. 3

The initial environmental impacts of the incident were contained within the close proximity of the
vessel. 2, p. 8

The incident involved the activation of Queensland’s disaster management arrangements. 2, p. 9

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Activation of Local Disaster Management Groups (LDMGs) 2, p.9

Activation of the
Rockhampton Disaster District Management Group (DDMG) 2, p. 9

Involvement of the State Disaster
Coordination Centre (SDCC) 2, p. 9

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Shen Neng 1 incident response involved four components

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An environmental assessment including physical impacts, and preparation for a potential environmental
response including shoreline clean-up 2, p. 9

Compliance / enforcement investigations and prosecutions. 2, p. 9

An oil spill response operation 2, p. 9

The predominant focus of the Shen Neng1 incident response related to the ‘casualty’ – that is, the condition
and safety of the grounded vessel and its crew. 2, p. 9

The SDCC also contacted the Australian Defence Force (ADF) Duty Officer 2, p. 11

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A Great Barrier Reef Marine park Authority investigation and report which provides a summary assessment of the impacts
of the ship grounding on the marine habitats of Douglas Shoal. 3, p. 1

Direct and photographic assessments by divers of damage 3, p. 1

Chemical analyses of sediments samples for antifoulant paint contamination 3, p. 1

Multi-beam sonar and towed video surveys provided by the Australian Institute of Marine
Science. 3 p. 1

The Great Barrier Reef region covers
346,000 square kilometres from the tip of Cape York in the north to just south of Lady Elliot Island. 4, p. 1

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It
The GBR includes about 70 Commonwealth and Commonwealth-owned islands but excludes the 980 Queensland islands and the internal waters
of Queensland. 4, p. 1

Approximately 70% of the Region lies within Australia’s Exclusive Economic Zone (EEZ), as defined by the
United Nations Convention on the Law of the Sea (UNCLOS) 4, p. 1

The shallow water around Douglas Shoal was not visible to the crew on the evening of the grounding 1, p. v

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Chinese has seven differing dialects as well as hundreds of spoken languages.

or gate OR

The chief mate nodded off.

The chief mate went to sleep.

There were no marking buoys. 1, p. 44

There were no warning lights. 1, p. 44

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The chief mate had only had about 2½ hours sleep in the preceding 38½ hours before the grounding. 1, p. 18

Fatigue can have a range of effects on human performance: slowed reaction time; decreased short-term memory; reduced attention; decreased work efficiency; reduced motivation; increased variability in work performance; and increased errors or omission. 1, p. 20

Shen Neng 1 grounded on Douglas Shoal, about 50 miles north of the entrance to the port of Gladstone. 1, p. 40

There were no visual cues to warn either the chief mate or the seaman on watch about the hazard of the shallow water around Douglas Shoal when it was directly ahead of the ship ' 1, p. 44

Inmarsat-C satellite communications terminal 1, p. 2

Monitoring and surveillance systems 1, p. 4

Automated alarms are used to monitor the ships within the REEFVTS coverage area 1, p. 4

A salvage operation 2, p. 9

The Shen Neng 1 is owned by Chinese company Shenzhen Energy Transport. 1, p. 1

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The Shen Neng 1 is managed by Chinese company Tosco
Keymax International ship management
company 1, p. 1

Tosco Keymax International is responsible for ensuring fatigue management on board the Shen Neng 1. 1, p. 1

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The Australian Transport Safety Bureau recommends that Tosco Keymax International takes further safety action to address the fatigue mengagement safety issue.
1, p. 43

The ATSB remains concerned that there is no proper guidance provided to the master or crew with regard to how fatigue levels should be managed and when someone should make the fact known that they might not be fit to undertake a navigational watch. 1, p. 43

The ATSB report states: 'There was no effective fatigue management system in place on board Shen Neng 1 to ensure that the bridge watchkeeper was fit to stand a navigational watch after the loading in Gladstone.' 1, p. 43

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Shen Neng 1’s safety management system (SMS) contained two procedures that dealt with hours of work on board. 1, p. 24

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'However, the procedure did not provide the crew with any practical guidance on how to manage the fatigue levels of watchkeepers.' 1, p. 24

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'The minimum rest period procedure was based on the fitness for duty provisions of the STCW Code (Section A-VIII/1). The words used in the procedure were virtually straight from the Code.' 1, p. 24

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In addition to section A-VIII/2 part 3-1 (18) of the STCW Code, section 3.2.6 of the International Chamber of Shipping’s Bridge Procedures Guide28 states: 1, p. 25

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'The OOW29 should not hand over the watch if there is any reason to believe that the relieving officer is unfit to, or temporarily unable to, carry out his duties effectively. If in any doubt, the OOW should call the master.' 1, p. 25

Part A of the Code, Chapter VIII deals with standards regarding watchkeeping. Section A-VIII/1 (Fitness for duty) states: 1, p. 23

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'Notwithstanding the provisions of paragraph 1 and 2, the minimum of 10 hours may be reduced to not less than 6 consecutive hours provided that any such reduction shall not extend beyond 2 days and not less than 70 hours rest are provided each 7-day period,' 1, p. 23

'The requirements for rest periods laid down in paragraphs 1 and 2 need not be maintained in the case of an emergency or drill or in any other overriding operational conditions.' 1, p.23

'The hours of rest may be divided into no more than two periods, one of which should be at least 6 hours in length.' 1, p. 23

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Regulation VIII/1 (Fitness for duty) of the STCW Convention states:
'Each administration shall, for the purpose of preventing fatigue': 1, p. 23

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Management is responsible for ensuring the International Convention on Standards of Training, Certification and Watchkeeping (STCW Convention) and the Seafarers’ Training, Certification and Watchkeeping (STCW) Code requirements are adhered to. These amendments include measures aimed at the preventing fatigue in ship’s watchkeepers. 1, p. 23

'Require that watch systems are so arranged that the efficiency of all watchkeeping personnel is not impaired by fatigue and that duties are so organized that the first watch at the commencement of a voyage and subsequent relieving watches are sufficiently rested and otherwise fit for duty.' 1, p. 23

'All persons who are assigned duty as officer in charge of a watch or as a rating forming part of a watch shall be provided a minimum of 10 hours rest in any 24-hour period.' 1, p. 23

'Illness or the effects of fatigue, alcohol or drugs could be reasons why the relieving officer is unfit for duty.' 1, p. 25

The only guidance the procedure contained was the statement:
'Authorities and responsibilities
The master is responsible for managing working hours of all crew members except the chief engineer who has no navigational watch.' 1, p. 24

'Consequently, the ship’s master was expected to effectively manage the levels of fatigue or tiredness of the watchkeeping officers without the provision of any practical guidance from the ship’s SMS.' 1, p.24

'Establish and enforce rest periods for watchkeeping personnel' 1, p. 23

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The shallow water around Douglas Shoal was not visible to the crew on the evening of the grounding 1, p. v


In the 30 minutes leading up to the grounding, there were no visual cues to warn either the chief mate or the seaman on lookout duty, as to the underwater navigation hazards directly ahead of the ship [Significant safety issue].' 1, p. 44

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There were no marking buoys. 1, p. 44

There were no warning lights. 1, p. 44

An amendment to the Great Barrier Reef Marine Park Act 1975 made it an offence to navigate a compulsory pilotage area without a pilot 4, p. 3

At the time of the grounding, the protections afforded by a requirement for compulsory pilots were not in place in the sea area off Gladstone. [Significant safety issue] 1, p. 45

At the time of the Shen Neng 1 grounding REEFVTS coverage only extended to an area 120 miles north of Gladstone 1, p. 4