Lessons Learned: Misinterpretation of Navigation Aids
Misinterpretation of navigation aids contributed to a pilot launch running aground on a navigational hazard in Port Phillip Heads.
Following the grounding of one of its pilot transfer launches in Port Phillip Heads, a Port of Melbourne pilotage services provider has developed additional operational guidance on the use of navigation aids, such as launch equipment and crew resources.
On the evening of October 5, 2023, the pilot launch Corsair was returning through the entrance of Port Phillip after collecting a pilot from an outbound container ship, when it ran aground on Point Lonsdale Reef travelling at about 24 knots.
The coxswain, deckhand, and pilot were able to abandon the disabled launch onto the flat-top reef and were later rescued by one of a number of attending rescue vessels. Corsair was wrecked during the night by the effect of the sea and the reef.
An investigation into the grounding was conducted by the Victoria state government’s Office of the Chief Investigator (OCI), under the Commonwealth Transport Safety Investigation Act 2003, on agreement with the ATSB (Australian Transport Safety Bureau).
Chief Investigator Mark Smallwood said the investigation found the coxswain of the pilot launch had misinterpreted the navigation aids on Shortland Bluff and navigated to the west of their intended course through the entrance to Port Phillip.
“The incidence of human error can be reduced through effective use of available resources including a vessel’s equipment and crew,” Mr. Smallwood said.
“In this case, the coxswain relied on visual observations, and did not make effective use of available on-board navigational equipment.”
While not found to have contributed to the grounding, the OCI investigation made a number of findings relevant to Corsair’s operator, Port Phillip Sea Pilots. It was found that the pilot launch safety management system and procedures could be improved with guidance to the launch crew on operational practices and the effective use of the launch’s equipment and second crew member.
In addition, documentation supporting the training and competency assessment of launch coxswains was limited in detail and training records were incomplete.
In response, Port Phillip Sea Pilots has developed additional guidance material for pilot launch operations and the effective use of launch equipment and crew resources. This includes the review of risks associated with single person error and the updating of safety management systems.
Training of launch coxswains and deckhands in crew resource management has commenced and annual crew verification (check trips) are planned.
Read the ATSB report: Grounding of pilot launch PV Corsair, Port Phillip Heads (near Point Lonsdale), Victoria, on October 5, 2023. Publication date: 27/02/2025.
