Independent safety issue investigation into Queensland Coastal Pilotage

Maritime Safety Queensland

Great Barrier Reef and Torres Strait Vessel Traffic Service

Significant safety issue

The service can better support pilotage by:

• 
  ensuring REEFVTS’s electronic systems are optimally set up to ensure that a hazardous situation in any area, including areas where pilots usually leave the bridge to rest, is detected in adequate time to issue a useful warning to the ship(s) involved; and
  
• 
  equipping vessel traffic service operators with the training and knowledge to best use its systems to support pilotage.
  

Response from Maritime Safety Queensland

ATSB assessment of response

Australian Reef Pilots

Pilot fatigue management plan

Significant safety issue

Factors that limit the effectiveness of the fatigue management plan amongst the 82 pilots surveyed included the:

• 
  largely self-managed approach where individual pilots may have conflicting priorities relating to remuneration and other working arrangements; and
  
• 
  pilot travel and transfer times regularly being included in rest periods.
  

Response from Australian Reef Pilots

ATSB assessment of response

ATSB safety recommendation - MI-2010-011-SR-051

Risk event and incident reporting

Significant safety issue

Indicators of the inadequacies in risk management and/or under-reporting amongst the 82 pilots surveyed included:

• 
  significant under-reporting where the number of grounding or collision risk events claimed by pilots in 2010 was about 10 times the number included in AMSA and pilotage provider incident records; and
  
• 
  pilots citing reasons for under-reporting being personal disadvantage, lack of corrective action taken, no risk reduction and remuneration risk/organisational pressure.
  

Response from Australian Reef Pilots

ATSB assessment of response

ATSB safety recommendation - MI-2010-011-SR-052

Hydro Pilots

Pilot fatigue management plan

Significant safety issue

Factors that limit the effectiveness of the fatigue management plan amongst the 82 pilots surveyed included the:

• 
  largely self-managed approach where individual pilots may have conflicting priorities relating to remuneration and other working arrangements; and
  
• 
  pilot travel and transfer times regularly being included in rest periods.
  

Response from Hydro Pilots

ATSB safety recommendation - MI-2010-011-SR-053

Risk event and incident reporting

Significant safety issue

Indicators of the inadequacies in risk management and/or under-reporting amongst the 82 pilots surveyed included:

• 
  significant under-reporting where the number of grounding or collision risk events claimed by pilots in 2010 was about 10 times the number included in AMSA and pilotage provider incident records; and
  
• 
  pilots citing reasons for under-reporting being personal disadvantage, lack of corrective action taken, no risk reduction and remuneration risk/organisational pressure.
  

Response from Hydro Pilots

ATSB safety recommendation - MI-2010-011-SR-054

Torres Pilots

Pilot fatigue management plan

Significant safety issue

Factors that limit the effectiveness of the fatigue management plan amongst the 82 pilots surveyed included the:

• 
  largely self-managed approach where individual pilots may have conflicting priorities relating to remuneration and other working arrangements; and
  
• 
  pilot travel and transfer times regularly being included in rest periods.
  

Response from Torres Pilots

• 
  pilot allocation to a ship is determined by the provider’s operational staff based on the estimated time of arrival provided by its master;
  
• 
  pilot transfers are determined by the provider’s operational staff and not by pilots;
  
• 
  pilot rest breaks are calculated by the provider’s operational staff, including making allowances for pilot transfer times.
  
• 
  potential conflicts of interest with some disaffected pilots exaggerating or overstating potential safety issues to increase calls for the creation of a Government-controlled monopoly pilot service;
  
• 
  no linkage identified in the report to suggest that the financial interests of pilots and pilotage providers have any impact on safety;
  
• 
  separation of responsibilities between coastal pilots and providers means that each can focus on delivering an independent, high quality and safe service without potential conflicts of interest;
  
• 
  an Australia-wide shortage of pilots means sufficient work for pilots without any need for competition between them;
  
• 
  competition in the airline industry has not compromised safety standards; and
  
• 
  other self employed professionals, such as those in the medical profession, are also paid a fee for service.
  

ATSB assessment of response

ATSB safety recommendation - MI-2010-011-SR-055

Risk event and incident reporting

Significant safety issue

Indicators of the inadequacies in risk management and/or under-reporting amongst the 82 pilots surveyed included:

• 
  significant under-reporting where the number of grounding or collision risk events claimed by pilots in 2010 was about 10 times the number included in AMSA and pilotage provider incident records; and
  
• 
  pilots citing reasons for under-reporting being personal disadvantage, lack of corrective action taken, no risk reduction and remuneration risk/organisational pressure.
  

Response from Torres Pilots

• 
  confusion amongst pilots about what is a reportable incident or near miss or near grounding;
  
• 
  the absence of a no-blame environment with potential disincentive to pilots reporting incidents to AMSA, which is also responsible for licensing and enforcing safety regulations;
  
• 
  that claims of risk events and under-reporting in the report were based on hearsay and overstated; and
  
• 
  the reduced number of collision and groundings incidents since the introduction of safety management systems in 2001 despite an increase in ship traffic.
  

ATSB assessment of response

ATSB safety recommendation - MI-2010-011-SR-056

APPENDIX A: COASTAL PILOT SURVEY SUMMARY

As discussed in section 1.1.4, the ATSB completed a survey of all 82 licensed coastal pilots in February 2011. The 92 survey questions were based on pilot demographics, their confidential reports and safety concerns, and aspects of safety management.¹⁶¹ Pilots were provided with confidentiality of their survey responses under the provisions of the Transport Safety Investigation Act 2003.

The ATSB checked and validated the pilot survey responses before coding the data, where necessary, and analysing it. The following section contains charts displaying data for selected survey question responses. Most of the charts include data from more than one survey question response and, where relevant, the charts indicate other information, for example, the pilots’ pilotage provider. The survey data formed essential evidence for the investigation.

Survey data for the two pilots engaged by Hydro Pilots (HP), where appropriate, is shown separately. However, to make data for these two pilots statistically relevant, it has, in many cases, been combined with that of Torres Pilots (TP). Unlike pilots engaged by Australian Reef Pilots (ARP), the pilots engaged by HP and TP are transferred via Mackay Helicopters, and HP pilots are assessed by TP check pilots. Combining their data also helps prevent HP pilots being individually identified.

Survey Q 1: Which of the following is your age group?

Note: Fifty pilots (61 per cent) were over the age of 55.

Survey Q 3: Which of the following best describes your work as a pilot?

Note: Fifty-seven pilots (70 per cent) were working on a full time permanent basis.

Survey Q 5: Which coastal pilotage areas or routes are you licensed for?

Note: Two of the 69 pilots with an Inner Route licence did not hold a Great North East Channel licence.