The pilotage system used by Atlantic Blue’s pilot did not define off-track limits or make effective use of recognised bridge resource management tools in accordance with the Queensland Coastal Pilotage Safety Management Code and regular assessments of his procedures and practices under the code’s check pilot regime conducted over a number of years had not resolved these inconsistencies.
The ATSB is not satisfied that the action proposed by the Australian Maritime Safety Authority will, by itself, adequately address the safety issue because specific information obtained from AMSA in relation to its concerns about the operations of coastal pilots indicates that wider, significant safety issues may exist. Therefore, the ATSB will undertake a systemic, safety issue investigation into coastal pilotage which it aims to complete by the end of 2011. Safety issue investigation MI-2010-011 started 16/12/2010.
The Australian Maritime Safety Authority (AMSA) has advised the ATSB that a review of the coastal pilotage marine orders is being finalised. Changes will include an upgrade of check pilot procedures to promote more rigour and independence within the check pilot system. It is also intended to enhance pilot training and licence renewal requirements through the use of bridge simulators and additional testing and training requirements for trainee pilot licences. This training will focus on bridge team management, human factors and piloting to a passage plan. The marine orders will require standard passage plans to be employed and a consultative process to develop plans which are acceptable to all pilots is being progressed. The review into Coastal Pilotage Services in the Torres Strait and Great Barrier Reef by AMSA and the Department of Infrastructure, Transport, Regional Development and Local Government, commenced in July 2008, is being progressed. An independent, full review of the fatigue management plan is also to be completed. In its response, AMSA also advised that it has concerns that there may be systemic issues that could impact upon the safe operation of coastal pilots and the ability to fully develop a ‘safety culture’. These concerns are based upon reports from pilots raising various issues about safety and certain aspects of pilotage operations.
The ATSB is not satisfied that the action proposed by the Australian Maritime Safety Authority will, by itself, adequately address the safety issue because specific information obtained from AMSA in relation to its concerns about the operations of coastal pilots indicates that wider, significant safety issues may exist. Therefore, the ATSB will undertake a systemic, safety issue investigation into coastal pilotage which it aims to complete by the end of 2011.
