Poseidon Sea Pilots’ (PSP) safety management system for pilotage operations did not have procedures or processes to manage predictable risks associated with increased river flow or pilotage operations outside normal conditions. This, in part, resulted in PSP not considering risks due to the increased river flow properly and not taking an active role until after the breakaway.
The safety action taken to mitigate increased river flow and other extreme weather events adequately addresses the safety issue.
Poseidon Sea Pilots (PSP) advised the ATSB that over the 2 years since the incident, it has progressively taken various safety actions to address the safety issue. In collaboration with Maritime Safety Queensland (MSQ), PSP developed a set of structured emergency evacuation procedures to respond to increased flow in the Brisbane River. These procedures are part of the berthing and manoeuvring plans documented in its pilotage operations safety management system (POSMS). Further, PSP provided input for changes made to MSQ’s Port Procedures Manual, which was renamed as Port Procedures and Information for Shipping Manual.
In addition, PSP worked with MSQ using its bridge/ship simulator to develop generic emergency evacuation procedures that can be used as a guide for any berth in the port. Generic procedures for 8 berths/locations, including the Ampol Lytton Products Wharf, have been documented in the POSMS. This has been complemented by requiring all pilots to undertake at least one emergency evacuation procedure in the simulator as part of their continuous professional development program.
The POSMS was amended to include a new section titled Extreme Weather Events that provides general information and guidance for such events. All pilots have also been provided with MSQ’s Port Evacuation Guidelines (Brisbane). In addition, a procedure titled ‘emergency response’ in the POSMS that describes various aspects of emergency management clarifies that MSQ’s regional harbour master will manage all port emergencies with support provided by PSP.
