Marine safety investigations & reports

Independent investigation into the loss of containers from Pacific Adventurer off Cape Moreton, Queensland, 11 March 2009

Investigation number:
Status: Completed
Investigation completed


Download Final Report
[Download  PDF: 4.03MB]

At 0312 on 11 March 2009, the container ship Pacific Adventurer lost 31 containers overboard in gale force weather conditions and large swells off Cape Moreton, Queensland. All the containers sank, however, two of the ship's fuel oil tanks were holed as the containers went overboard.

About 270 tonnes of oil leaked from the holed tanks and 38 miles of Queensland's coastline was affected by the oil.

The ATSB investigation found that the ship was probably subjected to synchronous rolling at the time and that the severe and sometimes violent rolling motions caused the lashings on the containers, and possibly some the containers themselves, to fail. In addition, much of the fixed and loose container lashing equipment was in a poor condition and the inspection and replacement regime in the ship's safety management system had not been effectively implemented.

The ATSB identified four safety issues during the investigation: the inspection and maintenance regime of the ship's fixed and loose lashing equipment had been deficient; there was no requirement for a third party to inspect this equipment; the cargo in the containers which were lost overboard was not packaged in accordance with international dangerous goods shipping requirements; and the dangerous goods shipping compliance audit regime did not pick up on this fact.

Safety action to address the safety issues was taken by several of the responsible organisations. The ATSB has issued one safety advisory notice in regard to the outstanding safety issue concerning third party inspections of lashing equipment.


Updated: 22 July 2011
Following the release of the Pacific Adventurer investigation report, the ATSB was contacted by the German Federal Bureau of Marine Casualty Investigation (BSU) in relation to a number of accidents involving fatalities and serious injuries on board large German flagged container vessels as a result of severe ship motions in poor sea conditions. The BSU have commissioned a number of studies into container ship stability and the causes of severe rolling motions as part of their investigations and undertook to conduct a further study specifically into the circumstances of Pacific Adventurer's voyage on 10/11 March 2009.  The BSU is currently working through the International Maritime Organization to address the issue of 'excessive stability' on container ships in order to develop of a new generation of intact stability criteria.

The BSU's report: Theoretical Investigations on the Container Loss of MV Pacific Adventurer off Cape Moreton, Queensland; and their reports into two fatal accidents on board merchant ships during typhoons in the sea area off Hong Kong, can be downloaded from this webpage.

Download Final Report
[Download  PDF: 4.03MB]


Download Preliminary Report
[Download  PDF: 655KB]

Preliminary Report Released 14 April 2009

At 0312 on 11 March 2009, the Hong Kong registered container ship Pacific Adventurer lost 31 containers overboard in gale force weather conditions and large swells. The ship was about seven miles east of Cape Moreton, Queensland. All the containers, carrying ammonium nitrate prills, sank. However, two of the ship's fuel oil bunker tanks were holed as the containers went overboard. In all, Pacific Adventurer lost about 270 tonnes of fuel oil into the sea as a result of the damage caused to the bunker tanks.

Download Preliminary Report
[Download  PDF: 655KB]
General details
Date: 11 March 2009   Investigation status: Completed  
Time: 0312 (UTC+10)    
Location   (show map): off Cape Moreton   Investigation type: Occurrence Investigation  
State: Queensland    
Release date: 27 January 2011    
Report status: Final   Occurrence category: Serious Incident  
  Highest injury level: None  

Vessel details

Vessel details
Vessel Pacific Adventurer  
Flag Hong Kong China  
IMO 9003847  
Type of operation Container ship  
Damage to vessel Minor  
Departure point Newcastle, New South Wales  
Departure time 1738, 9 March  
Destination Brisbane, Queensland  
Last update 14 November 2018