1

Departmental investigationinto the

grounding of the German flagcontainer ship

CAROLAon South Ledge Reef in the

Great Barrier Reefon 30 March 1995

Report No 79

MIIU

2

Contents

Summary ....................................................................... 4

Sources of information ................................................ 6

Narrative ....................................................................... 7

Comment and Analysis ............................................. 15

Conclusions................................................................ 28

Submissions ............................................................... 29

Details of Ship ............................................................ 30

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Navigation Act 1912

Navigation (Marine Casualty) Regulations

investigation into the

grounding of the German flag container ship

CAROLA

on South Ledge Reef in the

Great Barrier Reef

on 30 March 1995

No 79

Published: July 1995

ISBN 0 642 19961 2

TInvestigation into marine casualties occuring within the Commonwealth's jurisdiction areconducted under the provisions of the Navigation (Marine Casualty) Regulations, madepursuant to sub section 425 (1) (ea) and 425 1 AAA of the Navigation Act 1912. TheRegulations provide discretionary powers to the Inspector to investigate incidents as definedby the regulations. Where an investigation is undertaken the Inspector must submit a reportto the Secretary of the Department. It is Departmental policy to publish such reports in fullas an educational tool.

To increase the value of the safety material presented in this report, readers are encouragedto copy or reprint the material in part or in whole for further distribution, but shouldacknowledge the source. Additional copies of the report can be obtained from:

Inspector of Marine AccidentsMarine Incident Investigation UnitDepartment of Transport and Regional DevelopmentP O Box 594CANBERRA ACT 2601

Phone: 06 274 7324Fax: 06 274 6699Email: MIIU@dot.gov.au

MIIU on the INTERNETInformation relating to this report and other marine investigation reports can be located fromthe Marine Incident Investigation Unit's Internet homepage at our URL:

http://www.miiu.gov.au

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SummaryThe German flag container ship Carola sailed from Sydney on theafternoon of 25 March 1995, bound for Singapore by way of the innerroute of the Great Barrier Reef.

At 0100 on 29 March, the vessel embarked a licensed pilot off Cairnsfor the passage through the inner route to Goods Island. The vesselmade good a speed of marginally over 15 knots.

At about 0230 on 30 March, the Pilot left the bridge in an area wherethere was to be no alteration of course for about two hours and whereother shipping and fishing boats presented no potential hazard. ThePilot gave clear directions to the Second Mate, the officer of thewatch, that he was to be called at a position that he had marked on thechart, or if the mate had any concerns.

At a little after 0400, the Mate relieved the Second Mate, who passedon the instruction about calling the Pilot.

At 0458 on 30 March, Carola ran aground on South Ledge Reef.

The Master, who was asleep in his cabin, was woken by the change inthe characteristic vibration of the ship. He went to the bridge wherehe found only the Mate and lookout. The Pilot was called from hiscabin.

The damage was assessed, soundings of the ship’s tanks were takenand the Marine Rescue Coordination Centre was informed. It wasestablished that the fore peak tank was breached and some water wasentering the bow thruster space. However, the ship’s pumps wereable to handle the ingress of water.

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No injury was sustained to the Pilot or any crew member and nopollution resulted from the grounding.

The Carola refloated about six hours later at 1115 on the high tideand, after the Master established that it was safe to do so, the shipcontinued its passage to Goods Island. It anchored off Goods Islandafter 1530. In the evening of 30 March, a surveyor from the ship’sclassification society boarded the vessel and over the next three daysthe vessel was inspected by divers and repairs carried out, to allow itto continue the voyage to Singapore.

Carola resumed its voyage on 4 April.

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Sources of information

The Inspector acknowledges the assistance of the following in thepreparation of this report:

The Pilot, Master and crew of Carola

The Safety Research Section of the Bureau of Air Safety Investigation

The Director, Aviation Medicine, Civil Aviation Authority.

Acknowledgements

Portions of charts Aus 4060 and Aus 839 reproduced by permission ofthe Hydrograhic Office, RAN.

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NarrativeThe German flag container ship Carola was built in Hamburg andcame into service in October 1994. It is 157.59m in length overall, ithas a moulded breadth of 22.92m and a moulded depth of 11.80m. Ata summer draught of 8.9m it has a deadweight of 14,911 tonnes andcan lift 1048 twenty foot equivalent unit containers in six holds andstacked six high on deck. The Master, the Mate, the two EngineerOfficers and the Boatswain were German nationals while theremaining 11 crew (including the Second and Third Mates) wereFilipino nationals.

Carola is powered by a single MaK diesel engine generating 9300 kW,which drives a single shaft and controllable pitch propeller, giving aservice speed of 18.8 knots. The vessel is so built that all fuel oiltanks, except one, are above the double bottoms.

The ship’s bridge is fitted with a dual command position with aconsole arranged around two chairs at the forward part of the bridge,each chair has a radar situated in front of it. The starboard chair hasthe propeller pitch (KaMeWa) control lever and the emergencytelegraph, together with the telephones to the accommodation andengine room. Between the two chairs on a central part of the consoleare the steering controls, gyro compass repeater and the “dead-man”alarm, which is always in operation while the ship is at sea.

The Master has the key to the dead-man alarm, which normally is setat 12 minutes, and retains it in his possession at all times. The alarmhas a display which shows the minutes and seconds remaining beforea reset is necessary. If the alarm is not reset before the twelve minuteperiod, the light displaying the seconds flashes and a low tone audiblealarm sounds. If not cancelled from either the console or at the charttable, the general alarm sounds after one minute, waking all hands.

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During the hours of darkness a seaman is assigned to lookout duties,at other times the seaman is in easy reach of the bridge.

The vessel sailed from Sydney at 1655 on 25 March, bound forSingapore by way of the inner route of the Great Barrier Reef. As a“regulated” ship, within the meaning of the Great Barrier Reef MarinePark Act 1975, being over 70m in length and navigating betweenCairns and Cape York, Carola was required to take a duly licensedpilot.

The vessel arrived off Cairns fairway buoy at 0100 on 29 March,having made good a speed of 15.69 knots, and embarked a licensedpilot. The Master and Pilot exchanged routine information regardingthe ship and the intended passage, with the deepest draught stated tobe 8.6m. At 0220, Carola passed Low Islets at the start of thecompulsory pilotage, the Second Mate was officer of the watch.

The weather was fine and clear and remained so throughout thepassage.

The pilotage is about 470 miles in length between Low Islets andBooby Island and at a speed of just over 15 knots the Pilot couldexpect to disembark at about 0800 on 30 March, a pilotage time ofabout 30 hours. The practice is for the pilot to take a rest, or sleep inareas where other shipping, fishing vessels and the weather permit.Under favourable circumstances there are four opportunities to rest:between Low Islets and Rattlesnake Point, Archer Point and ThreeIsles, across Princess Charlotte Bay and from south of CairncrossIslets to Wyborn Reef. On a ship of Carola’s speed, the “rest” breaksvary from about one hour to a maximum of two hours underfavourable circumstance.

The Pilot had been engaged by the ship on a previous occasion andwas confident of the ability of the ship’s officers. The Pilot left thebridge a little while after passing Low Islets, after establishing thecourse and assessing the traffic situation. He left instructions to be

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called south of Gubbins Reef at about 0500 and pointed out that theofficer of the watch would need to adjust course by seven degrees atabout 0450. At 0400, the Mate relieved the Second Mate who passedon the Pilot’s instructions in his general hand over. The Mate alteredcourse from 343° to 336° at 0448 and duly rang the Pilot at theallotted position. The Pilot answered the phone immediately and wentto the bridge, where he found everything operating normally. Afterpassing Gubbins Reef at 0525 and Archer Point at about 0600 andwith Carola on a steady course of 002°, the Pilot left the bridge for arest of about 70 minutes. He left a position marked on the chart, threemiles south of Three Isles light, with instructions to be called at thatpoint, if not required before.

At about 0730, the Mate called the Pilot in the designated position.Again the Pilot answered the telephone promptly and went to thebridge to take charge of the navigation.

At 0800, the Third Mate relieved the Mate as officer of the watch.The passage continued routinely in fine weather. The Pilot remainedon the bridge, in charge of the navigation until about 1400 when offCape Flinders where he left the bridge for about 50 minutes, returningto the bridge at Wharton Reef.

The Master spent prolonged periods on the bridge, being presentduring both of the watches maintained by the Third Mate.

When called at Wharton Reef at about 1450, the Pilot remained on thebridge for about nine hours until about 2350, after rounding ClerkeIsland. He left the bridge until called at about 0115 at a positionsouth-east of Hannibal Island, when he returned to the bridge.

At about 0124 on 30 March, Carola passed Hannibal Island andcourse was altered to 006° to pass to the east of Halfway Island andCairncross Reef. At about 0215, the ship passed to the east ofHalfway Island and at 0224 altered course to 340°. With little

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shipping movements or fishing boats in the area, the Pilot decided thathe would take a rest while the ship was on a straight run to WybornReef. He instructed the Second Mate to call him if in any doubt aboutother traffic or if in any way concerned. The Pilot also marked aposition on the chart, four miles before the alter course position offWyborn Reef, at which he required to be called. He left the bridge atabout 0230, expecting to be called at a little before 0430.

The seaman on the 12-4 watch called his relief at about 0340 and at0345 the Second Mate rang the Mate, to call him for the 0400 to 0800watch. The Mate responded to the call. The 4-8 seaman lookoutarrived on the bridge at about 0355 and the 12-4 lookout left thebridge a little after 0405. The Mate, who normally arrived on thebridge at 0355 had not arrived at the time the seaman left the bridgenor did the seaman pass the Mate on his way to his cabin on “A”deck.

The Mate arrived on the Bridge at a time between 0405 and 0410. Aswas his usual practice, he checked the ship’s position and marked iton the chart with the notation 0400. The Second Mate stated that hemade a cup of coffee for the Mate, as he normally did. The Mateseemed normal and listened to, and seemed to understand, the handover information. He was specifically told of the presence of a ship onthe port bow (at that time about five miles off), Carola’s course andspeed, the position at which the Pilot was to be called and the time ofthe alteration off Wyborn Reef, just after 0440. The Second Mate leftthe Mate in charge of the watch.

The Mate marked the ship’s position on the chart at about 0418 and0430. He stated that at the position shown on the chart he dialled thenumber to the Pilot’s cabin and allowed it to ring five times butreceiving no reply, replaced the handset. After fixing the position at0430 he sat in the starboard chair.

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A little before 0500, the Master, who was asleep in his cabin awokeattributing it to a change in the ship’s vibration. He immediately wentto the bridge where he saw the Mate at the chart table apparentlymarking the ship’s 0500 position on the chart. The Master realisedthat something was wrong and looking at the radar realised the shipmust be aground. He also realised that the Pilot was not on the bridge

Great Barrier Reef - Inner Route

12

and telephoned the Pilot, who responded after two rings of thetelephone. The Master told him that the ship was aground and thePilot immediately went to the bridge.

It was established that the ship had grounded on South Ledge Reef, at0458 on a heading of 340°.

Between 0500 and 0503 the Master reduced pitch on the propeller.At 0502, the engine room alarm sounded and the Duty Engineer gotup and went to the engine room where he found the bilge alarm in thebow thrust room was sounding.

From 0503 to 0640, the propeller pitch was put astern, but the shipwas firmly aground. The Marine Rescue Coordination Centre wasinformed of the grounding. The Master also contacted the ship’sowner in Hamburg and maintained contact throughout the rest of theday.

The level of liquids in the ship’s tanks and void spaces was monitoredfrom the engine room control room and it was established that the forepeak tank and the bow thrust space were taking water. The ship’spumps were set to pump the spaces and this controlled the ingress ofwater. The two junior officers were called and the depth of wateraround the ship was checked. As best as could be established, theship was aground in the forward part, but the after two thirds of theship was afloat.

The Australian Maritime Safety Authority navigation aids vessel CapeGrafton was anchored off Wyborn Reef, where it was to conductroutine maintenance on the light during daylight on 30 March. TheMaster of Cape Grafton offered to stand-by Carola, an offer whichwas accepted.

The tide in the area was on low water when the ship grounded and itwas decided to wait until high water, at about 1100, before trying torefloat the vessel and the Master set about supervising the

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redistribution of weight on board to trim the ship by the stern,including the filling of the after peak tank and swimming pool with seawater. At about 0900, the Master sent the Mate to supervise themovement of some of the forward containers to after stowage.

At about 1000, the Propeller Pitch was put astern. At 1115, just asthe tide started to fall, the ship gained sternway and refloated. Aninitial inspection confirmed that no oil pollution had been caused bythe grounding and the water in the forepeak and bow thrust space wasbeing kept in check by the ship’s pumps. The ship’s draught had notaltered appreciably and the Master decided to continue passagethrough the Prince of Wales Channel. After consultation between theMaster, the Owners, the Pilot and the Australian Maritime SafetyAuthority, the vessel was taken to anchor west of Booby Island forfurther examination by the ship’s classification society.

The vessel arrived at the anchorage west of Booby Island withoutfurther incident and anchored at 1544. The Pilot disembarked at1640.

The Classification Society surveyor boarded at 1845 and made aninitial internal inspection. He found the ship to be significantlydamaged, but of particular concern was the damage between the forepeak and the bow thrust space, where the collision bulkhead was splitand leaking water.

The following morning the Australian Maritime Safety Authoritysurveyor stationed at Cairns and an investigator from the Departmentof Transport’s Marine Incident Investigation Unit boarded the vessel.

The Classification Society Surveyor decided that temporary repairswould have to be completed before the ship could continue. Over thenext two days, divers conducted an underwater survey, determiningthe extent of the damage. A split in the hull in the fore peak wascleared of coral debris, which caused the water in the fore peak torise, the ship’s pumps not able to counter the ingress of water. This

14

split was subsequently filled with wood wedges to stem the water.Cracks in the steel work were covered with compound, or welded andcement boxes were also used to affect the temporary repairs. Thevessel was able to resume its voyage to Singapore on 4 April.

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Comment and Analysis

GeneralWhen the ship grounded it was carrying about 570 tonnes of heavyfuel, 46 tonnes of diesel oil and 13 tonnes of lubricating oil. All exceptabout 150 tonnes of the oil was in tanks above the double bottomtanks, and the 150 tonnes in a double bottom tank was contained in anarrow, longitudinal tank arranged along the line of the keel, about45m x 4m, with its forward bulkhead about 76m from the stem. Thechances of pollution was therefore relatively slight.

Extract from chart Aus 839 showing position of grounding

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Carola was a new and well found ship. All the ship’s equipment wasworking and no mechanical defect was involved in the accident.

All navigational aids in the area of Wyborn Reef and South LedgeReef were working correctly.

The possibility that mechanical failure, or local navigational aids orinformation in some way contributed to the grounding can be ruledout. The grounding was due to human factors related to those onboard Carola on 29/30 March, particularly the Pilot, the Master andthe deck officers.

The International Chamber of Shipping publication “BridgeProcedures Guide” covers the conduct of the master and officer of thewatch when a pilot is embarked at paragraph 3.10.

3.10 Navigation with Pilot Embarked (see Bridge Check list 5)

3.10.1 The presence of a pilot does not relieve the master or theofficer of the watch of their duties and obligations.

3.10.2 The Master should inform the pilot of the ship’scharacteristics using a pilot card. . . . The master shouldrequest information regarding local conditions and hisnavigational intentions. This information should be in aform to enable the master or officer of the watch tomonitor the planned passage.

3.10.3 The officer of the watch should cooperate closely with thepilot to assist him where possible and to maintain anaccurate check on the ship’s position and movements. Ifthe officer of the watch becomes unsure of the pilot’sactions or intentions, he should seek clarification and, ifstill in doubt, should inform the master immediately andtake the necessary action before the master arrives on thebridge.

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These requirements were substantially met until after 0400 on30 March.

Those involved in the navigation of the ship were appropriatelyqualified and experienced.

The Pilot had started his seagoing career in 1974 and gainedexperience on a wide variety of ships, including time on Australiannavigational aid vessels. He had three years experience as a masteron deep sea bulk carriers. He became a licensed pilot in October1993 and Carola was his 104th transit as a pilot.

On 22 March, after two to three days at home, the Pilot had joined aship off Cairns for a return voyage to Weipa. After the north boundpilotage he had about three days without duties on board and after hedisembarked off Cairns at 1900 on 27 March, he had a further twodays and nights rest period before joining Carola at 0100 on29 March. These breaks, together with the recognised rest periods ontransit on 29 March, would suggest that he had followed a routinewhich should have been sufficient to avoid any undue fatigue.

He had piloted Carola in early February, when the ship had beenunder the command of a different master and a different mate hadbeen on board. The Second and Third Mates, however, had been onCarola at that time and, based on his previous experience, heanticipated and found a well run and efficient ship.

The Master accepted the Pilot’s routine and recognised the need forthe Pilot to rest as sensible, given the length of the passage. The Pilotmarked the charts with the intended route, with all alteration of coursepositions marked clearly.

The weather was fine, the visibility clear and the ship was notconstrained by its draught in any part of the inner route. In theMaster’s opinion and given his knowledge of his officers, there wasnothing that should have prevented any one of them from alteringcourse should, for any reason, the Pilot be absent from the bridge.

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The Master had been at sea since 1959 and had been in commandsince 1972. He had joined Carola in Singapore on 9 February 1995.He organised his daily routine around the 8-12 watch maintained bythe junior and least experienced officer, the Third Mate. With aroutine of resting in the afternoon he normally went to bed aftermidnight and awoke before 0700 and he had maintained this normalroutine from Sydney.

He found his officers to be conscientious, keen and efficient, however,in restricted waters he tended to maintain a presence on the bridgeduring the Third Mate’s watch. Although not a teetotaller, he seldomdrank alcohol on board and had not drunk any in the days precedingthe grounding.

Following the grounding, the Master showed a high level ofseamanship and judgement in redistributing ballast, oil and containersand in refloating the ship.

The Mate joined Carola at Singapore on 9 March 1995. Reports ofhis conduct and ability received by the Master indicated that he was aconscientious officer, willing and eager to learn. He held a GermanMaster A.G. certificate of competency (equivalent to a Master Class 1Certificate), issued on 20 February 1995. He first went to sea in 1979and, apart from 18 months military service, he had been a seafarersince that time. In 1987 he obtained a license as a Master (MiddleTrade) and gained experience on a dredger and on “two watch”middle trade vessels, (with a master and one mate). He joined thecompany in 1993, initially on “two officer” ships before beingappointed to Carola.

On Carola he followed a typical Mate’s routine, keeping the 4-8watch. He was responsible to the Master for the cargo and, throughthe boatswain, the work of the deck ratings. After standing themorning watch from 0400 to 0800, he routinely worked through themorning until lunch time, rested in the afternoon for two hours, stood

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his afternoon watch (1600-2000) and normally went to bed between2200 and 2300. He stated he had maintained this routine for thevoyage from Singapore to Melbourne and from 25 March, when thevessel departed Sydney, to noon 29 March.

Given the experience of the Mate as an officer on ships carrying onlya Master and Mate, the prevailing fine conditions, the width of thechannel and the straight forward nature of the Mate’s duties, it wasreasonable for the Mate to have been left in sole charge of thenavigation of the vessel, while the Pilot was absent from the bridge.

The two junior mates were conscientious and capable and both hadjoined the ship in Hamburg at the end of September. Both hadcompleted a number of transits of the Great Barrier Reef, one of thesetransits with the Pilot on board for the transit of 29/30 March.

Communications between the German and Filipino staff was inEnglish. Communications between the officers was at a high level ofproficiency, the Master being fluent in English, while the three matesspoke English very well, although not with total fluency. The twolookouts interviewed were also proficient in English.

Underlying factors leading to the groundingThere are two main issues relevant to the grounding:

i the absence from the bridge of the Pilotii the conduct of the Mate.

There was no evidence that either illicit or prescribed drugs werefactors in the grounding. Alcohol in the form of beer and wine wasavailable to the crew on board, though spirits were specificallyprohibited. Examination of the ship’s records on purchases of beerand wine indicated only a moderate number of purchases, with noneseeming excessive.

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Before the Pilot arrived on board, the fridge in the Pilot’s cabin wasstocked with mineral water, Coca Cola and a pack of six 33cl bottlesof Holsten beer at 5.2 per cent alcohol by volume.

At 0500 on 30 March, the Master was not only dismayed that thevessel had grounded but also, when he went to the bridge immediatelyafter the grounding, was concerned that he smelt what he believed,based on his experience, was alcohol on the Mate’s breath.

Neither the Pilot nor the Mate were examined by a medicalpractioner, and the investigator arrived on the ship about 30 hoursafter the incident. In considering aspects of the performance of thePilot and Mate, the Inspector consulted a qualified psychologist fromthe Bureau of Air Safety Investigation (an expert in humanperformance) and the Director of Aviation Medicine of the AustralianCivil Aviation Authority (an expert in alcohol related issues).

The PilotThe cabin assigned to the Pilot was two decks below the bridge. Thecabin was not that usually used by the pilots, but next door to it, witha one digit difference in the telephone numbers, “33” rather than“32”.

During the period on the bridge from about 1450 to 2350 on 29 Marchthe Pilot had taken two meals, which were served to him on thebridge, at his request. The meals were supplemented by a drink ofCoca Cola, from the fridge in his cabin. The air temperature was inthe high twenties with relatively high humidity.

At 2350 on 29 March, the Pilot stated that he left the bridge and wentto his cabin. Anticipating a break of over an hour he opened one ofthe bottles of beer and drank part of the bottle. There was no rubbishbin in the cabin, so he replaced the bottle, with some beer remainingin it, in the fridge. He lay down and slept, until woken by thetelephone at about 0115 when he returned to the bridge and navigated

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the ship from a position south-east of Haninibal Island until, at 0225,the ship was clear of Halfway Island and steady on a course of 340°.The Pilot left the bridge for an anticipated two hour break and laydown in the cabin assigned to him. The next thing that he was awareof was the ringing of the cabin telephone. When he picked it up it wasthe Master, telling him that the ship was aground. He immediatelywent to the bridge.

A bottle of beer with between six - eight cl of beer remaining wasfound in the fridge by the Inspector when he inspected the cabin on 30March.

The Master stated that at 0500, the Pilot answered almost immediatelythe telephone rang, the phone ringing only twice before beinganswered. When the Pilot arrived on the bridge, shortly after, he wasalert and the two men were in close proximity by the chart table whenthey initially spoke to each other. The Master stated that he couldneither smell or otherwise detect alcohol on the Pilot’s breath, nor didthe Pilot in any way act as though he had been drinking.

Based on this, the interviews of the Master, deck officers andlookouts, and the fact that the Pilot went to the bridge when called at0115, the Inspector is absolutely satisfied that the Pilot’s statement onthe amount of beer consumed is correct. The question therefore is,would about 29 cl of beer at 5.2 per cent alcohol adversely affect thePilot’s performance. Having sought expert opinion the Inspector issatisfied that this amount of beer would have had no effect on thePilot’s conduct or efficiency and the consumption of a part bottle ofbeer consumed just before midnight on 29 March, neither affected thePilot’s performance at 0115, nor can it account for the Pilot sleepingthrough a properly delivered call from the bridge.

The Mate

The Master had confidence in the Mate based on his own experienceof the Mate’s attitude since joining the ship three weeks earlier and the

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favourable reports from another Master. There was no evidence thatthe Mate was on a course of prescribed drugs or that he took anyillicit drugs. As far as can be established he suffered no unduepersonal problems or other stress related condition.

His shipboard routine over the 104 hours, between leaving Sydney andcoming on watch at 0400 on 30 March, involved no extraordinaryduties and provided the normal rest periods for an officer keeping the4-8 watch. He was considered to be a conscientious and keen officerand a failure to maintain a proper watch was out of character.

The passage of 29/30 March was the Mate’s first transit of the innerroute of the Great Barrier Reef. In his first watch between 0400 and0800 on 29 March, he had called the Pilot as required on twooccasions. There is nothing to suggest that he did not understandwhat was expected of him or his duties with respect to the navigationof the ship.

The Mate was uncharacteristically late on watch on the morning of 30March, coming to the bridge between 0405, after the 12-4 lookout hadleft, and 0410. He stated that he had been to the laundry on the maindeck to check on some washing. The Mate fixed the position of theship as soon as he arrived on the bridge and marked it as 0400, aboutnine minutes out in time. The Second Mate stated that there wasnothing unusual in the Mate’s behaviour and he was not concerned toleave the watch to him.

The 4-8 lookout, who was stationed on the port side of the bridgehouse, recalled the Mate coming to the bridge and moving about,walking behind the chart console, occasionally sitting and some timesgoing to the chart table. The “dead-man” alarm was operating and hecould see its lights, but as the general alarm did not operate hebelieved the Mate must have cancelled it. He saw a ship on Carola’sport bow and, although he could only see bright deck andaccommodation lights and no navigation lights, it was apparently on a

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reciprocal course. He reported the ship to the Mate. Otherwise therewas no conversation between the two men. He did not recall theMate using the telephone and, as it was dark, doubted if he would seehim doing so. The seaman lookout also reported that, for about 20minutes the Mate seemed to be behaving normally.

The Lookout stated that, at about 0430, the Mate sat in the starboardconsole chair and thereafter did not move until the vessel grounded,when he went to the chart table.

The Mate stated that he recalled going to the bridge and receiving afull hand over briefing from the Second Mate. He understood that hehad to call the Pilot and knew that the course had to be altered offWyborn Reef. He did not remember any vessel (Cape Grafton) beingat anchor off Wyborn reef or any other ship being in the area.

He stated that he telephoned the Pilot, dialling 33 on theaccommodation telephone (the adjacent engine room phone had nodial facility). The ship would have reached the position marked by thePilot at about 0425.

He recalled sitting in the starboard chair after he fixed the ship’sposition. He watched the radar and set the bearing cursor and rangering for the alteration of course. He described his state as being awareof everything that was going on but unable to react.

Shortly before 0500, he felt the ship stop and he realised it must beaground. He went to the chart table and was fixing the ship’s positionwhen the Master came to the bridge.

Initially, during the interview with the investigator, the Mate stated thathe had followed his normal daily routine on the previous day. Afterhis evening meal, the Chief Engineer and Boatswain joined him in hiscabin to watch a video. He stated that he had just one bottle of beerduring this time and his normal consumption was one or two bottlesper day. He recalled that the video finished between 2200 and 2300

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and this, together with the statement about consuming only one bottleof beer, was confirmed by the Boatswain and the Chief Engineer ,who as duty engineer made his routine nightly visit to the enginecontrol room. The Mate stated that he then went to bed at about hisnormal time.

The Mate had made no purchases of alcohol during the first elevendays on board. His first purchase was made after sailing fromMelbourne on 22 March, when his account shows that on 23 Marchhe purchased a case of 24x33 cl bottles of Holsten beer. This wasfollowed on 26 March, by the purchase of a four litre cellar pack ofwhite wine.

Subsequently, the Mate stated that on the night of 29 March, he hadgone to bed at 2300 and had read in bed for about 45 minutes, whilehaving a further glass of wine. Therefore, he went to sleep betweenone and two hours after his normal stated time and he had, at most,four hours sleep before being called. However, expert advice is that inisolation, this should not have impaired his performance.

When asked to account for the consumption of alcohol over the fournights, he stated that he shared his beer and wine, and usually had aglass of wine with his evening meal. He also stated that after thegrounding, when excused the anchor watch on the afternoon of 30March, he also drank a number of glasses of wine.

This would not seem to be an excessive consumption of alcohol andcould account for the consumption of beer and wine over six days(with about 30 hours in Port Botany), however it would be normal forthose sharing beer with others to receive, at least some, in return.

On 31 March, some 20 hours after the grounding, the Mate could notproduce any of the beer he had purchased and only a very smallamount of wine remained in the cask.

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It is the Inspector’s opinion that the Mate had consumed more alcoholon the evening of 29 May than he initially admitted, however there isno independent means of fixing the amount consumed with anyaccuracy. He admits to consuming between three and four “standarddrinks” over a period of a little under four hours. This amount ofalcohol taken over this period should not account for any measurablelevel of blood alcohol four hours later. It would also be more unlikelythat the smell of alcohol would carry over after a cup of coffee.

If he had consumed twice the amount of beer or wine, six to eight“standard drinks, it would also be unlikely, given consumption over afour hour period and a little under four hours sleep, that there wouldbe sufficient alcohol to affect or impair performance under normalcircumstances with daylight stimuli. However, this amount of alcoholwould probably be detectable on the breath at 0500, even afterdrinking a cup of coffee between 0410 and 0430.

Dead

man’s

alarm

VHF

Steering

controls

Auto pilot

Rudder angle

indicator

Gyro

ARPA

KaMe Wa propellor pitch

controlAccommodation

telephone

Engine

room

telephone

Starboard control position

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From a little after 0430, the Mate was not in a fit condition, fromwhatever cause to maintain a navigation watch. Advice from humanperformance and medical experts was that the Mate either fell asleep,fell into a doze (loosing sense of time and space) or suffered someepileptic form of event.

There were a number of well understood elements relevant to thebridge that may explain his inability to maintain a watch. On theprevious evening, he could have reasonably anticipated that the Pilotwould be on the bridge at 0400, and it is possible that his attitude wasaffected by a diffusion of responsibility, through expectation of an“easy” watch, with somebody other than himself having charge of thenavigation.

Also, between 0400 and 0600 in the morning are those at which thebody has the least resistance to fatigue. The ambient temperature at acomfortable 27 degrees Celsius, near total darkness, the regularrhythm of the engines and the glow of the radar are all recognised aspotentially inducing drowsiness or even sleep. These coupled with ashorter than normal sleep, limited exterior stimuli and the normaldepressive effect of alcohol, could induce a state of lethargy anddrowsiness.

The evidence is that the dead-man alarm was cancelled as required.Set at 12 minutes, it would have had to have been cancelled on at leastfour occasions after the Second Mate left the bridge and at least twiceafter 0430. There is no evidence that anybody other than the Matecancelled the alarm. If the Mate was dozing or in a semi consciousstate for what ever reason, either the flashing light of the dead-manalarm, or its low tone alarm, could have triggered a conditionedresponse and the Mate automatically pressing the reset button.

Although intoxication is an obvious and economical explanation forthe Mate’s non-performance, there is no proof available to theinvestigator that this was the case. Other elements, as describedabove could equally provide an environment of near or actual sleep.

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In the absence of any medical condition, such as an epileptic event,the Inspector is satisfied that the most probable cause of the Mate’sfailure to keep an effective watch was through drowsiness that, fromjust after 0430, led to him dozing off, through the effects of the normalshipboard environment at the time of depressed circadian rhythmcoupled with the normal depressive effect of alcohol imbibed theevening before. It is not likely that his blood alcohol level was suchthat alcohol directly affected his abilities.

The issue of whether or not the Mate attempted to call the Pilot atabout 0424 cannot be resolved absolutely. On the balance ofprobabilities it seems that the telephone in the Pilot’s cabin did notring. It may be that the Mate either did not ring or rang the wrongnumber, 32 rather than 33, the cabin next door to the one in which thePilot was resting. Regardless of whether the Mate rang the correctnumber, he did not repeat the call, nor did he send the lookout tophysically check on the Pilot.

Past Incidents

The Inspector notes that since 1985, 23 incidents of grounding orcollision involving trading ships in the Torres Strait or Great BarrierReef have been reported. Nine of these ships had a qualified pilot onboard. Three incidents of grounding occurred in the Torres Strait,where the pilot was actively overseeing the navigation.

The other six incidents occurred in the inner route (three collisionswith small fishing boats and three incidents of grounding), and in eachcase the pilot was resting and not actively engaged in the navigation ofthe ship at the time of the incident. Of these six incidents, five haveoccurred between the hours of 0100 and 0500.

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Conclusions

These conclusions identify the different factors contributing to theaccident and should not be read as apportioning liability or blame toany particular organisation or individual.

1. The grounding was not due to any mechanical failure on boardCarola or any deficiency in the navigational aids marking the reef.

2. The grounding was the result of the Mate neither ensuring thePilot was called to the bridge at the designated position, nor alteringcourse in the Pilot's absence.

3. The Mate was overcome by drowsiness which caused him toloose track of time and space.

4. The Mate’s condition was induced by both an intake of alcoholsome four hours before going on watch and reduced sleep time. Hiscondition was compounded by the ambience of the bridge and theavaliablity of a comfortable chair at the command position. Thecondition on the bridge were not under the control of the Mate,however any intake of alcohol and duration of sleep were under hiscontrol.

5. The rest periods taken by the Pilot, under the prevailingconditions of weather and shipping traffic, were reasonable and inaccordance with the practice of Reef Pilots.

6. The part bottle of beer consumed by the Pilot just beforemidnight on 29 March would not have impaired his performance orefficiency.

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Submissions

Under sub-regulation 16(3) of the Navigation (Marine Casualty)Regulations, if a report, or part of a report, relates to a person’s affairsto a material extent, the Inspector must, if it is reasonable to do so,give the person a copy of the report or the relevant part of the report.Sub-regulation 16(4) provides that such a person may provide writtencomments or information relating to the report.

The report was sent to the Pilot whose submission has been reflectedin the report.

The report was also sent to the Master and Mate, neither responded tothe invitation to provide written comments or information.

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Details of Ship

Name Carola

IMO No. 9072109

Flag German

Classification Society Germanischer Lloyd

Ship type Container

Owner Reederei Heinz GeorgVoga KG

Year of build 1994

Builder J J Sietas, Hamburg

Gross tonnage 11,063

Net tonnage 6448

Summer deadweight 14,911 tonnes

Length overall 157.59m

Breadth extreme 22.92m

Draught (summer) 8.9m

Engine MaK

Engine power 9300 kW

Crew 16 (German/Filipino)