Senior crew members on the ship that crashed into and sank two tugboats in Tasmania's north-west last year had not undertaken required training, with a report into the incident finding lessons from previous close-calls had not been acted on.
Cement carrier Goliath rammed and sank the two stationary tugboats in Devonport in January 2022, causing millions of dollars' worth of damage.
No-one was injured but the collision resulted in months of disruptions.
The Australian Transport Safety Bureau (ATSB) has released its final report into the collision, which occurred after an incorrect steering setting was selected, resulting in the ship to speed up.
It found the ship's master and second mate had not undertaken required bridge resource management training, described as a "universally accepted tenet" to the safe navigation of ships.
Goliath's safety management system included requirements for deck officers to be provided with the relevant training and the ATSB said the training would have "provided the officers with the techniques and tools to support effective" management of the ship's bridge.
"That in turn would probably have resulted in the single person errors that contributed to this accident being detected and the collision prevented," the report said.
"The various concepts, techniques, and attitudes that together comprise bridge resource management remain among the most effective measures available to identify and eliminate, or rectify, human error."
The officers on the bridge were described in the report as "distracted" by radio traffic and the master's perception of risk "had probably diminished over time due to complacency".
The report also detailed Goliath had previously been involved in another two incidents involving the steering system, where the ship made contact with the shore or wharf and, on one occasion, narrowly avoided collision with a tug boat.
"While acknowledging that Goliath's current managers were not the ship's managers at the time, these earlier incidents, and the potential lessons learned, offered valuable opportunities to prevent future incidents," the report said.
The design of the ship's joystick system was also identified as having increased the risk of the crash as it was "misleading and did not provide a positive visual confirmation that the correct steering mode had been selected".
"The design of bridge systems can also play a part in mitigating the risks of human error by incorporating intuitive and conspicuous indications of correct operation and conversely, of errors or incorrect settings."
According to the report, the TasPorts risk assessment for Devonport had considered the potential for collisions in the area, but "the risk of injury to personnel on board those smaller vessels was not specifically considered".
Long, complex job to retrieve tugs
Since the incident, Canadian-based shipping company CSL, which operates the vessel, arranged for all deck officers to attend bridge resource management training and has had the ship's joystick panels modified.
A requirement for the training has also incorporated into crew schedules across other CSL ships.
TasPorts has also proposed several safety actions, including to ban Goliath using the swing basin in the Port of Devonport if vessels are berthed where the collision occurred.
The incident prompted a swift environmental response and the operation to salvage the tugs and remove them — which was described as one of the most-complex retrievals undertaken in Australia in recent years — took almost seven months.
The release of the final report comes just weeks after the ship was briefly banned from Tasmanian waters after it experienced engine failure while departing Devonport.
TasPorts said "human error" was to blame but the ban was overturned after the shipping company provided a report detailing remedial actions following the incident.
