Lessons Learned: Distraction, Ineffective Bridge Management

Ineffective bridge resource management and distraction contributed to boxship’s collision with tall ship Leeuwin.

With Ineffective coordination, distraction, and monitoring by the crew and harbor pilots on board the container ship Maersk Shekou contributed to its collision with the tall ship Leeuwin II in the Port of Fremantle.

On the morning of August 30, 2024, the Maersk Shekou was navigated into Fremantle Port by two pilots. As the ship was inbound, it experienced strong winds including a southwesterly squall of about 50 knots in the inner harbor entry channel. 

As the ship passed the wheel over point for the inner harbor, it did not turn. Instead, the ship traveled in the direction of Victoria Quay, where it subsequently collided with the STS Leeuwin II and the wharf edge.

While the Maersk Shekou sustained minor damage in the accident, the STS Leeuwin II sustained substantial damage and two of its crew sustained minor injuries. 

What the ATSB found

The ATSB (Australian Transport Safety Bureau) found that as the Maersk Shekou was approaching the charted wheel over point at South Mole, the pilot did not provide the helmsman with a course alteration instruction. While the pilot used a combination of the four available tugs and the ship’s main engine to turn the ship, the helmsman’s attempts to maintain the ship on the previously instructed heading prevented the turn into the inner harbor.

It was also identified that monitoring required of the entire bridge team was inadequately implemented, with improper oversight maintained during the pilotage. Further, the secondary (monitoring) pilot was occupied in nonessential phone activity at the critical stage of the passage. 

Finally, the ATSB found that several risk controls established by Fremantle Ports for the safe operation of ships had not been adequately implemented.

What has been done as a result

As a result of this occurrence, Fremantle Ports has taken the following action:

• Updated its procedures to clarify the daylight entry requirements for large container vessels (LCVs) ‘turning on arrival’ maneuver into port. In addition, it is in the process of conducting validation trials for nighttime ‘turning on arrival’ maneuvers, following the installation of an additional aid to navigation and simulation training of the pilots.
• At the time of writing, it is in the process of implementing a passage monitoring and auditing software to assist with identification of noncompliances.
• The secondary pilot’s role during a two-pilot operation shall be reiterated through a Harbor Master’s Instruction (HMI), after consultation with Fremantle Pilots.
• Updated its procedures relating to the usage, attachment, and release of tugs.
• Implemented several improvements to weather monitoring, such as:
  • the inclusion of squall alerts from Fremantle Ports’ weather service provider
  • proposed installation of additional wind monitoring equipment in port waters to improve decision-making capability
• Focused training of vessel traffic service operators, in relation to monitoring and ‘challenge and response’ activity.

In addition, Fremantle Pilots has taken the following proactive safety action:

• LCV in/outbound procedures have been updated to include the fourth tug to align with LCV overview procedure
• LCV procedures were reiterated to the pilot group (highlighting use of mobile phones, wheel over point, speed management, tug placement, daylight definition)
• Fremantle Pilots has also worked with the Fremantle Ports harbour master to implement a revised HMI for mobile phone usage during towage and pilotage
• utilized the Maersk Shekou event during emergency simulations conducted in October 2024
• added the Maersk Shekou event to emergency simulation exercise matrix for all pilots
• worked with Fremantle Ports to revise the definition of daylight
• the tug rendezvous point for all three- and four-tug inner harbor inbound jobs (includes all LCVs) was revised and amended to a position adjacent to Gage Roads N4 anchorage (in collaboration with Svitzer and Fremantle Ports).

Safety message

A properly functioning bridge team requires that all its members maintain a shared mental model to actively monitor the ship’s progress. To ensure this is effective, where deviations from the passage plan are required, this information should be conveyed to all members of the team. Similarly, actions that are incorrect or missed should be immediately identified, communicated, and rectified. 

Distractions on the bridge should be minimized, especially during critical stages of a passage. Several maritime accident investigations, both in Australia and overseas, have highlighted the use of mobile phones during critical phases of the passage as possible contributing factors. In 2020, the Australian Maritime Safety Authority released an advisory notice to say pilots should have their phones turned off or in silent mode when conducting a pilotage. This will minimize the potential distraction for the bridge team and the pilot.

Further, due regard should be given to the risk controls that ensure safe port operations. The dynamic nature of marine operations often results in actual conditions varying from those expected. It is essential that any associated risks and consequences, particularly those affecting predefined limits, are carefully reassessed and communicated between all concerned parties so that safety is not compromised. 

Content/image source/credit: ATSB (Australian Transport Safety Bureau), “Collision between container ship Maersk Shekou and tall ship STS Leeuwin II, Fremantle, Western Australia, on August 30, 2024,” publication date: 3/11/2025.