At 0235 on 9 May, a Port Phillip pilot boarded the ship for its departure. At 0539, in order to slow the rate of starboard turn, the pilot ordered 5° port rudder. However, the rate of turn to starboard increased so he ordered 10° port rudder, and then 20° port rudder. This was followed by an order of hard-to-port. On each occasion, the helmsman correctly repeated the pilot’s orders but applied starboard helm. Consequently, the ship’s rate of turn to starboard rapidly increased. At 0540, when they realized that the rudder was at hard-to-starboard, both the master and pilot yelled ‘hard-to-port’ to the helmsman. The helmsman then applied the correct helm. The ship, however, was still turning to starboard and grounding was imminent. At about 0541, despite various engine and rudder movements, Francoise Gilot grounded between beacons 18 and 20; about half the ship’s length passed over the toe line 4 of the channel before it came to a complete stop.
1 | Incident snapshot
| Grounding time (LT) | 05:41 |
| Manoeuvre in progress | 90 ° starboard turn around Hovell Pile beacon to enter the South Channel |
| Pilot’s orders | “Starboard 5”, “Midships”, then “Port 5 … Port 10 … Port 20 … Hard-to-port” |
| Execution error | Helmsman repeated each order but applied starboard helm—rudder reached hard-starboard |
| Consequence | Grounded between beacons 18 and 20; refloated two hours later; no damage |
ATSB found the helmsman was likely fatigued, and neither the pilot nor master was monitoring helm movement at the critical moment.
2 | HOM cue applicable to this error
| On-screen cue | High-level trigger* | What it tells the bridge team |
|---|---|---|
| WRONG HELM banner + brief audible signal | Rudder begins moving opposite to the spoken helm order | “Wheel is the wrong way—correct immediately.” |
*Detection logic confidential; only visible behaviour shown. Cue is advisory—no control lock-out or acknowledgment.
3 | Alternate timeline with HOM active
| Real time | Event | HOM cue | Likely bridge response |
|---|---|---|---|
| 05:39:30 | Pilot issues first “Port 5” order | — | — |
| 05:39:32 | Helmsman turns wheel 5 ° starboard | WRONG HELM banner appears + brief audible signal | Pilot & master see mismatch; order immediate port wheel |
| 05:39:45 | Wheel now to port, rudder swinging correctly | Banner clears automatically | Turn follows planned track |
| 05:41 | (Grounding in reality) | — | Vessel remains in channel; no grounding |
4 | Safety margin gained
- Detection speed: Wrong-direction helm flagged in seconds while ship still > 0.2 NM from the shoal edge.
- Track margin: Correcting to port 20 ° at that point keeps the vessel inside the dredged channel.
- Operational impact: No need for ballast transfers, tugs, or post-incident inspections; schedule remains on time.
5 | Why the single cue is effective
- Uses standard bridge phraseology—instantly clear to multinational crews.
- Stays visible as long as the rudder deflection is wrong, providing a continuous prompt without alarm overload.
- Leaves the conning officer fully in command; HOM simply surfaces the error.
Take-home message
Francoise Gilot grounded because a simple wheel-direction mistake went unnoticed until it was too late. Helm Order Monitor’s WRONG HELM banner and short sound signal would have highlighted that mismatch almost instantly, giving the bridge team the clear prompt needed to correct the helm and complete the turn safely.
