Marine safety investigations & reports

Fatality aboard Western Muse

Investigation number:
Status: Completed
Investigation completed


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At 0712 on 18 June 2002, the Panama flag bulk carrier Western Muse berthed at Port Kembla, NSW, to load a cargo of steel slabs and coils for Pohang in South Korea. The vessel had been chartered for the voyage by BHP Transport and Logistics.

The cargo was to be loaded using the ship's cranes. The master was advised to ensure that the cranes and wires were in good condition as they would be inspected by the stevedores before being used. Before the vessel's arrival at Port Kembla, after checking the cargo gear, both the master and mate were satisfied that the cranes and wires were in good condition.

The stevedore's inspection of the cargo gear started soon after the vessel had berthed, but unsuitable weather conditions led to only one crane being checked that day. The next morning the other cranes were inspected and, as a result, the mate was told to change the cargo wire of no. 2 crane.

During the remainder of that day, the crew carried out the task of changing the wire. Much of the work was carried out from the platform on top of the crane, requiring the use of safety belts.

By about 1745 the wire had been changed. The bosun, who was on the platform on top of the crane, gave the order for the operation of the crane to be checked. He then released the clip on the rope lanyard attached to his safety belt from railing on the platform. At the same time, the deck cadet, who had been operating the crane, raised the cargo hook, then the jib.

The lanyard on the bosun's safety belt was drawn into the sheaves for the jib, dragging the bosun in between the sheaves and the luffing wire. He screamed out and one of two seamen with him immediately shouted to the cadet, by handheld radio, to stop the crane.

By the time the bosun was freed, he was haemorrhaging severely from wounds to his leg and pelvis. The master asked for ambulance assistance and, by about 1830, paramedics and a police rescue squad were in attendance on the ship. Soon afterwards, one of the paramedics advised the master that the bosun was dead.

The police forensic squad arrived to carry out their work and, at about 2230, the bosun's body was removed from the top of the crane and taken to the mortuary. The interim post-mortem report stated that the cause of death of the bosun was massive traumatic injuries resulting in amputation of the left leg and the side of the pelvis.

The ATSB investigation concludes that, among other factors contributing to the incident:

  • The task of changing the wire was physically and mentally demanding, possibly causing the bosun's concentration to lapse at the end of the day;
  • It is probable that the bosun was concentrating on the cargo wire and that he was not watching the luffing wire after he released the lanyard on his safety belt. In addition, poor light would have made it difficult to see any detail on the platform.

This report recommends that:

  • In accordance with the objectives of the ISM Code, companies, in addition to documenting preventive maintenance procedures, also develop, document and implement associated safety procedures;
  • Procedures and precautions for personnel working aloft include warnings that loose clothing or personal safety equipment might become entangled in moving machinery.


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

Based on the evidence available, the incident occurred due to a combination of the following factors:

  1. After the bosun released the rope lanyard on his safety belt, the lanyard became entangled in the luffing wire or was drawn into the sheaves for that wire, dragging him in between the sheaves and the wire.
  2. The task of changing the cargo wire, in addition to being arduous and lengthy, was physically and mentally demanding, possibly causing the bosun's concentration to lapse at the end of the day.
  3. The conditions of lighting under which the crew were operating at the top of the crane would have made it difficult to see any detail on the platform.
  4. It is likely that the bosun was concentrating on the movement of the cargo wire and that he omitted to watch for movement of the luffing wire.
  5. Though the mate had signed a permit to work that morning, the conditions for the permit were not re-assessed once darkness had fallen.
  6. While the company and the ship had the necessary ISM accreditation, the safety manual contained no precautions or procedures for the crew when working in close proximity to moving machinery on cranes.

In addition, although not a contributing factor, the Inspector concludes that the condition of the wire that was renewed did not meet the requirements of Marine Orders Part 32. The wire was not fit for use and, hence, did require replacing.

Download Final Report
[Download  PDF: 286KB]
General details
Date: 19 June 2002   Investigation status: Completed  
Location: Port Kembla    
State: New South Wales    
Release date: 01 May 2003   Occurrence category: Serious Incident  
Report status: Final   Highest injury level: Fatal  

Vessel details

Vessel details
Vessel Western Muse  
Flag Pan  
IMO 9234214  
Type of operation Bulk carrier  
Damage to vessel Nil  
Departure point Port Kembla, NSW  
Destination Pohang, South Korea  
  Crew Passenger Ground Total
Fatal: 1 0 0 1
Total: 1 0 0 1
Last update 19 May 2016