THE COXSWAIN of the Port Phillip Sea Pilot launch Corsair had misinterpreted the aids to navigation on Shortland Bluff and navigated to the west of their intended course through the entrance to Port Phillip when the vessel was wrecked in October 2023, the ATSB has found.

In its final report into the incident, released today [27 February], the Bureau says PPSP has developed additional operational guidance on the use of launch equipment and crew resources.

On the evening of 5 October 2023, Corsair was returning through the entrance of Port Phillip after collecting a pilot from the outbound container ship Rio Grande, 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 Victorian Government’s Office of the Chief Investigator, under the Commonwealth Transport Safety Investigation Act 2003, on agreement with the ATSB.

Chief Investigator Mark Smallwood said the investigation found “The incidence of human error can be reduced through effective use of available resources including a vessel’s equipment and crew. 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 PPSP. 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, PPSP 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, ATSB reports.