A final report has blamed fatigue and other safety issues for the grounding of a coal carrier on the Great Barrier Reef.
The Shen Neng 1 struck Douglas Shoal off the central Queensland coast on April 3 last year, gouging a 3km-long scar and spilling about four tonnes of heavy fuel oil from a ruptured fuel tank.
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In its final report on the incident, the Australian Transport Safety Bureau found the chief mate was fatigued and it affected his performance as he monitored the ship's position.
"The ship did not have an effective fatigue management system in place to ensure that the bridge watchkeeper was fit to stand a navigational watch," it found.
ATSB Chief Commissioner Martin Dolan said the grounding provided an important safety lesson for all seagoing vessels.
"Fatigue is one of the key safety risks facing seafarers, and watchkeepers in particular. Failure to manage fatigue can lead to loss of life, damage to property and damage to the environment," he said.
The ATSB urged ship operators to comply with international requirements that ensure operators properly manage the hours of work and rest of watchkeepers.
The report also identified several other safety issues relating to the accident.
It found the ship's safety management system did not contain procedures or guidance in relation to the proper use of passage plans, including electronic route plans.
In the half-hour leading up to the grounding, there were no visual cues to warn either the chief mate or the seaman on lookout duty about the underwater navigation hazards directly ahead of the ship.
It also noted that at the time of the grounding, protections afforded by compulsory pilotage and active monitoring of ships by the Great Barrier Reef and Torres Strait Vessel Traffic Service
(REEFVTS) were not in place in the area off Gladstone.
Queensland Premier Anna Bligh said GPS monitoring of vessels out of the Port of Gladstone would start on July 1.
"That means these vessels will be constantly monitored and if they are in any way off course that's a matter that can be immediately addressed," she told reporters in Ipswich.
"I think monitoring will go a long, long way into making the Great Barrier Reef a much safer place."
Recommendations
Meanwhile, the report makes two safety recommendations for the Shen Neng 1's management company relating to fatigue management and passage planning.
Mr Dolan said the ship's chief mate managed just 2.5 hours of sleep in the previous 38.5 hours as he supervised loading in Gladstone.
He said what occurred was a succession of quite simple and small errors on the part of a tired crew member.
"Any individual one of these things should have had some sort of other protection to stop it happening," he said.
"There was a sequence of things going wrong that led to a major failure which is quite often what we find in the course of our investigations.
"Fatigue remains a key risk in all transport sectors and needs to be carefully managed."
Mr Dolan said the ATSB had no power to enforce any action by ship operators.
Asked, however, if this incident had been a "wake-up call" to ship operators, he said it should be.
"What we are saying is that there should be consistent attention paid by people operating to the risk of fatigue.
"Fatigue can lead to a range of serious safety consequences."
Mr Dolan doubted such an accident could happen again because the reef vessel tracking system was now being extended to the seas off Gladstone.
It monitors ship positions and notifies them if they veer off track.
