River Embley arrived at the anchorage off Gladstone at 0902 on the morning of 14 October. After 'finished with engines', the diesel alternator was put on line and the steam plant was shut down to allow for repairs on the number two turbo alternator exhaust steam valve.

At about 1010, after checking that the exhaust steam system had drained, the chief engineer and third engineer started working on the valve. A short time later, while they were dismantling the valve a thousand litres of pressurised hot water unexpectedly started to spray from the valve and onto the chief engineer standing on staging below.

In an effort to escape the hot water spray the chief engineer tried to jump clear of the staging but became entangled in the securing rope which had formed a barrier.

The ship's crew mounted an immediate first aid response and the master organised a helicopter evacuation. The chief engineer was transported to Gladstone Hospital and later transferred to the Royal Brisbane Hospital intensive care unit.

The report concludes that the engineers did not fully assess the exhaust steam piping system and its drainage arrangements, or allow sufficient time for the exhaust steam system to completely drain before starting to work on the valve.

The ship's work permit system and job safety analysis procedures were not utilised by the engineering crew and deficiencies in safety management were not identified in two audits prior to the accident.
It is also considered that a sizable experience gradient between the chief engineer and the other engineers along with a lack of team training allowed a series of 'single person' errors to go unchecked and unquestioned.

The ATSB has made several safety recommendations aimed at preventing further accidents.