The Australian Transport Safety Bureau (ATSB) has found that human error caused the grounding of the Chinese-registered bulk carrier 'Shen Neng 1' on Douglas Shoal, about 80 kilometres north of the entrance to the port of Gladstone in the Australian state of Queensland on April 3, 2010.
The ship's hull was seriously damaged by the grounding, with the engine room and six water ballast and fuel oil tanks being breached, resulting in around four tonnes of heavy fuel oil being spilt on the World Heritage-listed Great Barrier Reef.
A report into the incident blames the Chinese operator, Tosco Keymax International Ship Management, for not implementing a fatigue management system to ensure that the bridge watchkeepers were fit to stand a navigational watch after they had supervised the loading of a cargo of coal in Gladstone.
The ATSB investigation found that the grounding occurred because the chief mate did not alter the ship's course at the designated course alteration position. His monitoring of the ship's position was ineffective and his actions were affected by fatigue.
The report also found that there was insufficient guidance in relation to the proper use of passage plans, including electronic route plans, in the ship's safety management system.
The ATSB has issued two safety recommendations to 'Shen Neng 1's' management company regarding the safety issues associated with fatigue management and passage planning.
The Australian Maritime Safety Authority has since extended its ship monitoring coverage to include the waters off Gladstone.