Marine safety investigations & reports

Crew member fatality on board British Mallard while berthed in Kwinana, WA

Investigation number:
Status: Completed
Investigation completed


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On the morning of 26 January 2007, British Mallard berthed at the BP Kwinana oil refinery jetty, Western Australia, to discharge its cargo.

At about 1750 on 27 January, the ship's engineers attempted to rectify an elevator fault that had been reported earlier in the day. After making some adjustments to the second deck elevator landing door switches, the electrical technician stepped onto the ladder in the elevator shaft. He then asked the second engineer to let the doors close behind him.

Soon after the doors closed, the elevator car travelled upwards and after a few seconds it stopped.

The second engineer could not open the second deck elevator landing doors. He called the third engineer, on his hand held radio, and told him to come to the second deck. The two men tried, unsuccessfully, to open the elevator doors.

The two men then went upstairs and opened the upper deck elevator landing doors. They looked down and saw the electrical technician. He had been trapped by the elevator car and he appeared to be unconscious. Shortly afterwards, the second engineer activated the general alarm.

The master reported the accident to the refinery operator while the crew tried to free the electrical technician.
Assistance arrived from ashore and, at about 1920, the refinery doctor examined the electrical technician and determined that he was deceased.

The report identifies a number of safety issues, safety action already taken, makes one safety recommendation and issues two safety advisory notices with the aim of preventing similar events.

Marine Recommendations [ MR20070023 ]

Marine Safety Advisory Notices [ MS2007005 ] [ MS2007006 ]

Download Final Report
[Download  PDF: 1.24MB]
General details
Date: 27 January 2007   Investigation status: Completed  
Time: UTC + 8 hours    
Location: Kwinana    
State: Western Australia    
Release date: 22 June 2007   Occurrence category: Incident  
Report status: Final   Highest injury level: Fatal  

Vessel details

Vessel details
Vessel British Mallard  
Flag IOM  
IMO 9282479  
Type of operation Tanker  
Damage to vessel Nil  
  Crew Passenger Ground Total
Fatal: 1 0 0 1
Total: 1 0 0 1
Last update 19 May 2016