Insufficient bridge resource management training due to collision that sank two tugs at Devonport, Australia

The Australian Transport Safety Bureau (ATSB) investigation into the collision between a bulk carrier and two tugboats in Tasmania last year underscores the importance of bridge resource management and the design of bridge systems to reduce the risk of human error.

On January 28, 2022, the Australian-flagged bulk carrier launched Goliath was turning in the swivel basin to dock in Devonport Harbour, Tasmania when she collided with two moored tugs, which subsequently sank.

Fortunately, there were no personnel on board the tugs at the time. Goliath suffered light damage.

As the ATSB explained in its preliminary report, GoliathThe master of had gone from the wheelhouse to the port bridge wing helm station to complete the turn.

“During this transfer of maneuvering control, the correct steering mode was not selected,” ATSB Chief Commissioner Angus Mitchell said. “As a result, the captain’s maneuvering commands, given in the belief that the ship was in joystick steering mode, had the unintended effect of increasing the ship’s speed as it approached the tugs.”

The ATSB established that neither the master nor the second mate attended Goliath had completed the required Bridge Resource Management (BRM) training, that BRM was not effectively implemented on board and effective BRM was not evident during the incident.

“It was determined that this was a contributing factor to this incident – a safety issue that has now been addressed by the ship’s operator,” Mr Mitchell said.

Since the incident, operator CSL Australia has taken care of all deck officers serving on board Goliath to attend shore-based BRM training and has incorporated BRM training into its fleet crew training schedule.

“The various concepts, techniques and attitudes that together make up BRM remain among the most effective measures available to identify and eliminate or correct human error,” said Mr. Mitchell.

In addition, the final report notes that the vessel operator had made changes Goliath‘s joystick panels to incorporate a positive visual indication that the joystick steering mode has been selected.

“Together with BRM, bridge system design can help reduce the risk of human error by incorporating intuitive and eye-catching cues for correct operation and vice versa for errors or incorrect settings,” concluded Mr. Mitchell.

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