Flinders Ports had not undertaken a risk assessment, or developed contingency plans for this specific shiphandling manoeuvre in Port Lincoln. Consequently, the pilot had no guidance regarding what actions to take if the berthing manoeuvre did not progress as he planned.
Amended risk assessments to include new preventative, as well as restorative, measures to be followed.
The ATSB has been advised that following the incident, Flinders Ports reviewed its risk assessments and contingency plans, together with a number of different manoeuvres for berthing. Taking into account the characteristics of the incident (engine going ahead rather than astern), similar risks were observed in all manoeuvres.
Flinders Ports has updated the risk assessments for manoeuvring and berthing a ship in the port. The Pilot and Port Notes have also been amended to take the risks and different manoeuvres into account. These notes now include courses and speeds to be followed during manoeuvring within the port.
The ATSB is satisfied that the action taken by Flinders Ports adequately addresses this safety issue.
