On 12 June 1996, the barquentine rigged STS Leeuwin was
cruising in the Timor Sea. On board, in addition to the permanent
and volunteer crew, were 31 trainees, mainly young unemployed
persons, drawn from all over the Northern Territory and sponsored
by the Commonwealth Employment Service.
Shortly after 0830, a team of three trainees, led by their Watch
Leader, climbed aloft on the mainmast, to release the gaskets
securing the main gaff topsail, so the sail could be set. The
second of the three trainees, a woman in her late twenties, fell as
she negotiated the futtock shrouds. Although she had clipped on her
safety line, the free end of her safety belt slipped through the
buckle and she fell 18 m to the deck.
Fortunately, the fall was partially broken by the nock sail
sheet. Even so, the trainee suffered severe multiple fractures to
her knees and to her thighs, also a collapsed lung. A helicopter
medivac was arranged to transfer her to the Royal Darwin Hospital,
where she remained in intensive care for 16 days.
Conclusions
These conclusions identify the factors contributing to the
incident and should not be taken as apportioning either blame or
liability.
The trainee fell from the futtock shrouds because, although very
frightened, she intentionally let go her hand hold in the belief
she would be all right.
The main contributing factors to the trainee's fall to the deck
are considered to be:
- The trainee had not fastened hersafety belt properly, so that
it came undone instead of preventing her from falling further.
- The absence of a safety check system, which meant that the
trainee was able to climb aloft with an improperly fastened safety
belt.
- The onboard philosophy and procedures that removed the safety
barrier of safety belt checks before trainees ventured aloft.
Other factors that are considered to have contributed to the
accident are:
- The onboard procedures that allowed a trainee to climb aloft
for the first time on the mainmast.
- The absence of an onboard philosophy or procedure whereby a
trainee with a slow learning capability is afforded supplementary
attention.
It is also considered that the shiny surface of the well-worn,
fine-weave webbing created difficulty in the tight fastening of the
safety belt, which may have contributed to the trainee not
fastening the belt correctly.
It is further considered that the trainee's death was averted
only by her left arm hooking over the nock sail sheet.
