Marine safety investigations & reports

Independent investigation into the fatality on board the Australian registered floating storage and offloading tanker Karratha Spirit, off Dampier, Western Australia, 24 December 2008

Investigation number:
261-MO-2008-013
Status: Completed
Investigation completed

Summary

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At about 1815 on 24 December 2008, the Australian registered floating storage and offloading tanker, Karratha Spirit, began disconnecting from its mooring buoy at the Legendre Oil Field, about 60 miles north of Dampier, Western Australia, because of an approaching tropical cyclone.

The master was on the forecastle, directly controlling the operation. Before the mooring hawsers could be released from the ship, the import hose drifted under the hawsers and he ordered the main engine to be run astern for about 1 minute in an attempt to pull the hose clear. At about 1954, after the wire suspending the oil import hose parted suddenly, the master ordered the crew to finish letting go the hawser pickup lines so that the ship could depart the mooring buoy.

An integrated rating applied the port winch drum's brake to stop the drum moving and then stepped between the cheeks of the drum to cut the lashing that held the end of the heavy hawser pick line on the drum. At about 1958, when the lashing parted, the last three turns of heavy line rapidly unwound from the drum, striking the rating on the head and throwing him under the winch drum. He died as a result of his injuries.

The ATSB investigation found the procedures for connecting and disconnecting from the mooring buoy had not always been followed and that the difference between the procedures and shipboard practice had not been identified during any shipboard review and the risks associated with this amended practice had not been assessed.

The investigation also found that it is possible, under some circumstances, that facilities like Karratha Spirit can fall outside the jurisdiction of the safety regulators. The report issues one recommendation and one safety advisory notice to address these safety issues.

Download Final Report
[Download  PDF: 2.35MB]
 
 
 

2011 update

In March 2011, the ATSB followed up progress with the National Offshore Petroleum Safety Authority (NOPSA). NOPSA advised the ATSB that the Department of Resources Energy and Tourism (RET) have further considered the issue of jurisdiction between NOPSA and the Australian Maritime Safety Authority (AMSA). NOPSA is aware that RET have been discussing options with both these agencies and RET are proposing to make clarifying amendments to the relevant legislation as part of a larger reform agenda and are targeting the winter 2011 session of Parliament.

Safety Issues

Go to MO-2008-013-SI-01 - Go to MO-2008-013-SI-02 - Go to MO-2008-013-SI-03 - Go to MO-2008-013-SI-04 - Go to MO-2008-013-SI-05 -

Procedures versus practices

The ship’s procedures for connecting and disconnecting from the CALM buoy did not provide explicit, succinct and unambiguous guidance and there were differences between the procedures and the actual shipboard practices that increased the level of risk associated with those operations

Safety issue details
Issue number: MO-2008-013-SI-01
Who it affects: All owners, operators, managers and masters of offshore production and supply vessels
Status: Adequately addressed

Shipboard review

The procedures for connecting and disconnecting the import hose and disconnecting from the CALM buoy in place on board Karratha Spirit were signed off as being satisfactory and reflecting shipboard practice, but they had not been effectively reviewed on board the ship. Consequently, the ambiguities in the procedures and the discrepancies between the procedures and the ship’s practices were not identified during any shipboard review or audit and were not made known to the ship’s managers through any review process.

Safety issue details
Issue number: MO-2008-013-SI-02
Who it affects: All owners, operators, managers and masters of offshore production and supply vessels
Status: Adequately addressed

Job Hazard Analysis review

The Job Hazard Analysis (JHA) for disconnecting from the CALM buoy did not provide an accurate assessment of the all of the hazards and associated risks in performing the task. In addition, the crew did not use it to assess the risks associated with undertaking an unfamiliar operation and it was reviewed without any involvement from the crew. Consequently, the JHA was not an effective means for assessing and controlling the risks associated with the operation of disconnecting from the CALM buoy.

Safety issue details
Issue number: MO-2008-013-SI-03
Who it affects: All owners, operators, managers and masters of offshore production and supply vessels
Status: Adequately addressed

Regulatory oversight

NOPSA does not undertake the audits necessary for maritime compliance and AMSA is only able to do so, while the facility is on station, with NOPSA’s cooperation. NOPSA had carried out annual occupational health and safety inspections on board the ship and AMSA had carried out the necessary third party audits of the system to meet its certification requirements. However, none of these audits or inspections had identified the discrepancy between the mooring hawser procedures and actual shipboard practices or that the ship’s internal review processes had not identified the discrepancy.

Safety issue details
Issue number: MO-2008-013-SI-04
Who it affects: All regulators, surveyors and inspectors
Status: Partially addressed

Jurisdiction

In this instance, the consensus of the regulatory authorities is that Karratha Spirit was not in a navigable form at the time of the accident and was therefore under NOPSA’s jurisdiction according to the OPGGSA. However, the point at which Karratha Spirit became ‘navigable’ is not clearly defined in the OPGGSA and is open to interpretation. Furthermore, had the accident occurred on board Karratha Spirit after it had departed the CALM buoy and while it was steaming off the coast to avoid a cyclone, without entering any ports, then it is possible that the ship would not come under the jurisdiction of any Australian safety regulatory regime.

Safety issue details
Issue number: MO-2008-013-SI-05
Who it affects: All regulators, surveyors and inspectors
Status: Adequately addressed
General details
Date: 24 December 2008   Investigation status: Completed  
Time: 1958 (UTC +9)   Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): Legendre Field    
State: Western Australia    
Release date: 28 September 2010    
Report status: Final   Occurrence category: Accident  
  Highest injury level: Fatal  

Vessel details

Vessel details
Vessel FSO Karratha Spirit  
Flag Aus  
IMO 8613748  
Type of operation Special Purpose Vehicle  
Damage to vessel Nil  
Departure point Legendre Field  
Departure time 2000  
Destination Sea  
Last update 14 November 2018