Human error caused HMNZS Manawanui wreck, says NZ interim report

Under the report, HMNZS Manawanui was conducting survey operations on the southern side of Apia, Samoa, on Saturday, 5 October this year.

The survey was conducted in a box-shaped area when the ship’s crew attempted a routine turn to starboard around 6.15pm. The crew attempted to turn off the 340-degree course to starboard towards an easterly course, but the ship did not respond as intended.

HMNZS Manawanui left the approved survey area, and in an effort to stop the ship, the crew conducted further actions that they believed should have resulted in the ship essentially braking. Instead, the ship started to accelerate towards the reef, grounding for the first time at or about 6.17pm at a speed of more than 10 knots.

HMNZS Manawanui then travelled around 635 metres before becoming stranded, grounding multiple times along the way.

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Full control of HMNZS Manawanui’s propulsion system was not regained until 10 minutes later, at 6.27pm, when the ship’s autopilot was disengaged. The inability to turn or stop the ship was due to the ship being in autopilot mode.

Chief of Navy Rear Admiral Garin Golding stood up a court of inquiry following the incident in order to understand the facts of what occurred.

“The direct cause of the grounding has been determined as a series of human errors, which meant the ship’s autopilot was not disengaged when it should have been,” RADM Golding said.

“The crew did not realise Manawanui remained in autopilot and, as a consequence, mistakenly believed its failure to respond to direction changes was the result of a thruster control failure.

“Having mistakenly assessed a thruster control failure, standard procedures should have prompted [the] ship’s crew to check that the ship was under manual control rather than in autopilot. This check did not occur. Remaining in autopilot resulted in the ship maintaining a course toward land, until grounding and eventually stranding.”

RADM Golding said why it happened and what would come next in terms of lessons learnt were still being worked on as part of the wider court of inquiry , which was expected to be completed in the first quarter of next year.

RADM Golding said that given human error was identified as the cause, a separate disciplinary process would need to be commenced once the court of inquiry had concluded.

As well as the primary cause, there were also a number of identified contributing factors leading to the ship’s grounding, which will be considered in more detail during phase two of the court of inquiry .

“To provide some immediate assurance, we have conducted a series of audits in the fleet and looked to implement initial lessons identified from the interim report around training, risk management, and improving relevant orders, instructions and procedures,” he said.

RADM Golding said he was grateful for the support from the Transport Accident Investigation Committee, the Royal Australian Navy, and Royal New Zealand Air Force for their support to the court of inquiry investigation, which used evidence collected through interviews with the crew, expert witnesses and data from the ship’s recordings to find the primary cause.

The New Zealand Defence Force remains thankful for Samoa’s ongoing support regarding the situation and is committed to working alongside Samoan authorities on the response, he said.

“I want to reassure the public of New Zealand that we will learn from this situation and that it is on me, as the Chief of Navy, to earn back your trust,” RADM Golding said.

“We have incredible people within our Defence Force who answer the call to serve every day. Much of their work is risky and involves decisions that can mean life or death. No one turns up to work to have a bad day.

“In this situation, we thankfully did not lose any lives, but lives have been affected nonetheless, and we continue to support and work closely with those who were onboard Manawanui on that day.”