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On 3 March 1994, the Australian flag tanker Australian Achiever arrived off the floating production storage offloader Griffin Venture off the north-west coast of Western Australia and drifted, during the morning, while awaiting a pilot.

Before morning tea, the Extra Second Engineer showed the Engineer Cadet, the forward domestic fresh water pump and gave him instructions on how to remove the pump to the workshop for overhaul, a task that the Cadet was to undertake after the morning tea break. The Extra Second, in preparation for removal of the pump, ensured that the pump starter isolator and selector switches were in the "off'" position. As the Extra Second was quite clear in his mind that the job involved no electrical work, the fuses were not removed and no "danger" tag was attached to the starter.

During the morning tea break, the Fifth Engineer who was the duty engineer for the day, responded to an engine room alarm which indicated a fault on the vessel's 24 volt DC system, a common cause for alarms.

Shortly after the tea break, the Fifth Engineer again responded to an alarm which he took to be another 24 volt DC earth fault, but which cleared as soon as he "cancelled" the alarm. Later evidence showed that it had been an earth fault on the 440 volt system, in all probability caused by the Cadet having come into contact with a "live" terminal within the starter box for the forward fresh water pump.

At approximately 11 13, some 34 minutes later, the Third Engineer came across the Cadet lying on the deck between the fresh water pumps and the calorifiers. He was not breathing and no pulse could be detected. The door to the starter box for the forward fresh water pump was open and the isolating switch was in the "on" position. The vessel's emergency team was called and resuscitation techniques were applied but without success.

A helicopter, attending the Griffin Venture, was tasked to land on the deck of Australian Achiever and to airlift the Cadet to hospital at Exmouth. Resuscitation techniques were applied throughout the flight but, shortly after arrival, the Cadet was declared dead by hospital staff.

Conclusions

These conclusions identify the different factors contributing to the accident and should not be read as apportioning blame or liability to any individual or organisation.

  1. The findings of the Coroner's inquiry were that the Cadet died by electrocution following contact between his right hand and a live terminal within the starter box for the motor on the forward domestic fresh water pump.
  2. The Cadet had been given the task of removing the forward fresh water pump for overhaul, a task which was well within his mechanical abilities. It is considered likely, although it cannot be stated with certainty, that he considered the fuses should be removed prior to commencing work and he was about to do this when he accidentally touched a live terminal with his hand.
  3. In order to open the front cover of the starter box to gain access to the fuses, it is necessary to turn the isolating lever to the "off" position. It seems that the Cadet, having opened the front cover, must have turned the isolating switch back into the "on" position, possibly using the spring-steel clip on his key-ring to obtain sufficient leverage.
  4. The reason for the Cadet having turned the isolating switch back to the "on" position is unclear. It may have been done during a momentary lapse in concentration or he may have been investigating the function of the interlock. The isolating switch is clearly marked showing the "on" and "off" positions of the small T-bar through the end of the spindle.
  5. The alarm for channel 212, recorded on the alarm print-out at a time equivalent to 1039 (ship's time), indicating an earth on the vessel's 440 volt system, was probably initiated by the contact between the Cadet and some live part of the starter for the forward domestic fresh water pump.
  6. The Fifth Engineer acknowledged the alarm four minutes later at 1043. As the alarm channel cleared as soon as the "cancel" button was pushed, he was uncertain as to which alarm had been activated and assumed that it was a repeat of the earlier alarm for an earth fault on the 24 volt DC system. The Inspector considers that, as the earth fault was shown as having cleared, there was not cause for further immediate action on the part of the Fifth Engineer.
  7. It is not known with certainty whether the Cadet's hand contacted a point in the starter which was at 440 volts or at the control circuit voltage of 110 volts. It is likely, in view of the 440 volt earth alarm recorded at 1039, that it was at 440 volts. In either case, however, heat and humidity in the engine room cause considerable perspiration which would have increased the current flow through his body and, particularly in the case of 440 volts, could possibly have aided in the initiation of an electrical arc. It is not known, either, exactly how long he was in contact with the supply of current as the alarm print-out indicates only the time between the initiation of the earth fault and the time that the alarm was "cancelled" in the control room.
  8. The procedures detailed in ASP Ship Management's "Safety and Emergency Procedures Manual", relating to machiney isolation, were not followed. The Extra Second Engineer stated that he had checked that both the selector switch and the isolator for the forward pump starter were in the "off" position. The job of removing the pump was not of an electrical nature and, for this reason, he had not carried out the usual precautions required before undertaking electrical work, such as removing the fuses and "tagging" the starter.
  9. The reason for the Cadet having opened the door of the starter cannot be known but, in order to do so, the isolator switch had to have been turned to the "off' position. If, as is possible, he opened it to remove the fuses then under these circumstances, whether or not a safety tag had been attached to the equipment would have had no bearing on the outcome of the incident.
  10. The Cadet was found lying on the deck shortly before 1113. No resuscitation techniques were applied before the Emergency Team arrived some minutes later. It was not known at that time that he was dead and, in the absence of a pulse or respiration, CPR should be applied immediately. It is acknowledged, however, that if the alarm at 1039 indicated the time he received the fatal shock, the outcome would have been no different.
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General details
Date: 03 March 1994 Investigation status: Completed 
Time: N/A Investigation type: Occurrence Investigation 
Location:NW Australia  
State: Western Australia  
Release date: 30 January 1995 Occurrence category: Serious Incident 
Report status: Final Highest injury level: Fatal 
 
Vessel details
Vessel: Australian Achiever 
Type of Operation: Bulk carrier 
Damage to Vessel: Nil 
Departure point:Durnai, Indonesia
Departure time:N/A
Destination:Griffin Venture, NW coast WA
 
Injuries
 CrewPassengerGroundTotal
Fatal: 1001
Total:1001
 
 
 
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Last update 18 May 2016