Marine Investigations

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ATSB - Investigation number: AO-2018-022

Collision with water involving twin-engine EC135 helicopter, VH-ZGA, 35 km north-west of Port Hedland, Western Australia, on 14 March 2018

Preliminary report published: 3 May 2018

Safety advisory notice

Action number: AO-2018-022-SAN-001

The Australian Transport Safety Bureau advises helicopter operators involved in overwater operations of the importance of undertaking regular HUET (helicopter underwater escape training) for all crew and regular passengers to increase their survivability in the event of an in-water accident or ditching.

ATSB - Investigation number: MO-2017-005

Collision between the tug Arafura Sea Delta and general cargo ship Thorco Crystal, Weipa Harbour, Qld. on 24 June 2017

Safety message from ATSB

Masters of ships and tugs, pilots and others involved in handling vessels in confined waters or in proximity to other vessels are reminded of the hazards posed by hydrodynamic interaction (interaction). An awareness of the pressure zones around a moving vessel and an appreciation of the effect of speed on interaction forces can help vessel handlers foresee a potential interaction situation developing and allow them to deal with it. The effects of interaction can be amplified by an increase in vessel speed, the presence of another vessel or if the flow of water around the vessel is influenced by tidal streams or by entering a narrow or shallow channel.

MAIB - Accident Investigation Report 8/2018

Groundings made by bulk carrier Ocean Prefect at Ahmed Bin Rashid Port, Umm Al Qaywayn, United Arab Emirates


On 10 June 2017, the UK registered bulk carrier Ocean Prefect grounded when approaching Ahmed Bin Rashid Port, in Umm Al Qaywayn, United Arab Emirates. The vessel was not damaged and was re-floated 12 hours later. During a second attempted entry into the port the following day, Ocean Prefect again grounded but, despite the breaching of three ballast tanks, the vessel continued to its berth. Two harbour pilots were on board during the groundings. There were no injuries or pollution.

Safety lessons (from MAIB)

  • the pilots had very limited local knowledge
  • the effect of a tidal set was contributory to both groundings
  • tidal stream data for the port’s approaches was very limited
  • the positions of the navigation marks used to indicate the limits of the port’s approach channel were potentially misleading
  • the port in Umm Al Qaywayn lacked resource and marine expertise

MAIB - Accident Investigation Report 21/2017

Accident during pilot transfer between general cargo vessel Sunmi and pilot transfer vessel Patrol with loss of 1 life - Location: River Thames, London, England.


At 1812 on 5 October 2016, a Port of London Authority sea pilot was in the process of boarding the Bahamas registered general cargo vessel Sunmi from the pilot launch Patrol when he fell and was crushed between the two vessels. He died at the scene despite prompt medical attention from Royal National Lifeboat Institution and local ambulance crew.

Safety Issues

  • Low freeboard pilot transfers involve risks that should be included in risk assessments for boarding and landing
  • The designated pilot boarding station on board Sunmi was not marked and the deck gate should not have been opened in preparation for the transfer as it was unsuitable
  • The pilot had ingested sufficient alcohol on the day of the accident for his blood to contain 122mg alcohol per 100ml of blood approximately 2 hours after reporting for duty. It is likely that the consumption of alcohol contributed to his fall

MAIB - Accident Investigation Report 23/2017

Grounding of the ultra-large container vessel CMA CGM Vasco de Gama, Location: Thorn Channel, Southampton, England.


In the early hours of the morning on 22 August 2016, the 399m long ultra-large container vessel CMA CGM Vasco de Gama grounded on the western side of the Thorn Channel whilst approaching the Port of Southampton. The vessel was the largest UK-flagged vessel at the time and had two of the port’s specialist container ship pilots onboard.

The ship ran aground on a rising tide and on a flat shingle/sand sea-bed. A combination of tugs and ship’s engines enabled it to be re-floated soon after grounding.

MAIB has embarked on a study into the human factors associated with the use of modern electronic navigation aids and the implementation of mandated navigation standards.

Safety Issues

  • The investigation found that the vessel’s bridge team and the port’s pilots had the experience, knowledge and resources available to plan and execute the passage effectively. However, the standards of navigation, communication and effective use of the electronic charting aids onboard did not meet the expectations of the port or the company.
  • A detailed plan had not been produced; the lead pilot had not briefed his plan for the turn round Bramble Bank; the bridge team’s roles and responsibilities were unclear. There was an absence of a shared understanding of the pilot’s intentions for passing other vessels, or for making the critical turns during the passage.
  • Neither the ship’s Electronic Chart Display and Information System (ECDIS) not the pilot’s Portable Pilot Unit (PPU) functionality were fully utilized and resulted in each system not providing adequate cross checks or alarms.
  • The increasing size of vessels within restricted waterways, is leading to reduced margins of operational safety, and therefore the importance of proper planning and monitoring of the passage cannot be overemphasised.

MAIB - Accident Investigation Report 3/2017

Collision between pure car carrier City of Rotterdam and ro-ro freight ferry Primula Seaways, Location: River Humber, England.


On 3 December 2015 the Panama registered pure car carrier City of Rotterdam collided with the Danish registered ro-ro ferry Primula Seaways on the River Humber. Both vessels were damaged but made their way to Immingham without assistance. There was no pollution and there were no serious injuries.

Safety issues

  • The pilot’s actions resulted from a ‘relative motion illusion’
  • Robust challenges to the pilot’s actions could have prevented his illusion from leading to the collision
  • Off-axis bridge windows and lack of visual references led to pilot’s disorientation
  • Ergonomic impact of innovative bridge design not fully assessed

Link to investigation on TSB website

Photo via Professional Mariner

TSB - Marine Investigation Report M12W0207

Striking of Terminal by Bulk Carrier Cape Apricot; Location, Roberts Bank, British Columbia


On 07 December 2012 at 0045 Pacific Standard Time the bulk carrier Cape Apricot, while under the conduct of a pilot, struck the causeway and conveyor system connecting Westshore Terminals berth 1 to the main terminal at Roberts Bank, British Columbia. As a result of the impact, the causeway and conveyor collapsed into the water, and the vessel's bow sustained damage. There was minor pollution and no injuries.


Findings as to causes and contributing factors

  • The Cape Apricot's direct course to Roberts Bank necessitated a tighter alteration of course to starboard and placed the vessel in a line of approach to the trestle.
  • Given the vessel's speed and direct approach, the pilot initiated the turn at an insufficient distance from the trestle.
  • The pilot had not ensured that both tugs were ready to assist with the turn prior to the vessel's arrival at the basin.
  • There were no established abort points planned or discussed.
  • Without effective communication regarding their shared mental model during the approach, the master and the pilot did not identify the developing risk as the manoeuvre progressed and did not take timely corrective action.
  • The Cape Apricot's turn to starboard was neither timely nor sufficient, and the vessel struck the trestle.

Findings as to risk

  • Without a safety management system in place, pilotage organizations may not properly identify hazards and mitigate them, thereby placing vessels at risk.
  • If VDR data, in particular bridge audio recordings, are not available to an investigation, this may preclude the identification and communication of safety deficiencies in order to advance transportation safety.

Other findings

The data from the portable pilot unit was integral to the investigation.

AMPI Australasian Marine Pilots Institute Limited
PO Box 576 Albion Qld 4010 Australia (view on map)